About You
First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Male
Female
Other
Cell Phone:
Other Phone:
Email:
Address:
City:
State:
Zip:
Occupation:
Employer:
How did you hear about our office?
Who is your dentist?
Please list other IMMEDIATE family members seen in our office and their relation to you?
Dental Insurance Information
Primary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
Social Security #/Member ID:
Birthdate:
Secondary Insurance
Insurance Company Name:
Group/Plan Number:
Insurance Company Phone:
Policy Holder's Name:
Social Security #:
Birthdate:
Medical Health Information
What is the reason you are seeking an orthodontic evaluation?
Have you seen an orthodontist previously?
Yes
No
Do you have or have had any of the following diseases or conditions?
Allergies (medicine or other)?
Yes
No
AIDS, HIV Positive?
Yes
No
Asthma?
Yes
No
Diabetes?
Yes
No
Drug or Alcohol Dependency?
Yes
No
Excessive Bleeding or Bruising?
Yes
No
Fainting Spells, Seizures?
Yes
No
Heart Defect, Heart Murmur, Heard Disease?
Yes
No
Hepatitis?
Yes
No
Herpes, Fever Blisters?
Yes
No
High/Low Blood Pressure?
Yes
No
Joint Replacement or Implant?
Yes
No
Latex Sensitivity or Allergy?
Yes
No
Metal or Nickel Sensitivity or Allergy?
Yes
No
Scarlet Fever, Rheumatic Heart Disease?
Yes
No
Stroke?
Yes
No
Tonsils or adenoids removed?
Yes
No
FEMALES: Are You Pregnant?
Yes
No
If you responded yes to any question, please explain:
Do you now or have you ever taken bisphosphonates, including Fosomax, Didronel, Boniva, Actonel, Skelid, or Zometa?
Yes
No
If yes, which drug?
Do you have any disease, condition, or problem not listed that you think we should know about? Please explain.
Please list any medications currently being taken (include non-prescription):
Signature:
Date: