Confidential Patient Information

Date:
Whom may we thank for referring you to our practice?
First Name:
Middle Initial:
Last Name:
Sex:
Age:
Birthdate:
Prefers to be called:
Phone #:
Cell #:
Email:
Address:
City:
State:
Zip:

Financial Party Information

Employed By:
Occupation:
Work Phone:
Marital Status:

Spouse's Name:
Occupation:
Work Phone:
Employed By:

If you have children, please list:

Child Name:
Birthdate:
Child Name:
Birthdate:
Person Responsible for Account:
Social Security #:
Main Phone:
Address:
City:
State:
Zip:
Business Phone:
Cell Phone:

Contact in Case of an Emergency

Name:
Phone #:
Cell #:

Dental Insurance

Primary Insurance Co:
Group Number:
Phone Number:
Ortho Coverage:
Insured's Name:
SSN #:
Birthdate:

Secondary Insurance Co:
Group Number:
Phone Number:
Ortho Coverage:
Insured's Name:
SSN #:
Birthdate:
Other Insurance Information:

Dental History

Patient Dentist Name:
Date of last visit Visit:

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Have there been any injuries to the face, mouth, or teeth?
Have you had or do you presently have any of the following habits?
Have you been informed of any missing or extra permanent teeth?
Are you aware of any sores, lumps or irritated areas in the mouth?
* Has an orthodontist been consulted previously?
If so, who? When?
Have you ever been treated for:
If so, by whom:
Do you have any speech problems?
Are you concerned or anxious about orthodotic treatment?
Are you concerned about the appearance of your teeth?
* Is there anything you would like to change about your smile?
If so, what?
What aspect of dental treatment are you most concerned with?
Reason for consultation (chief concern):
Has there ever been any orthodontic treatment for any other member of your family:
Were they satisfied with the results:
Dr. who treated children:
Dr. who treated Spouse:
Dr. who treated other family:

Medical History

Is your general health good at this time?
Is the patient now under the care of a physician at this time? If so, please explain:
* Are you taking any medication?
If so, what:
* Are you allergic to any medication? (Penicillin, Sulfa, etc.
If so, what:
Have you ever had a serious illness or hospitalization? If so, what for?
* Have you had your tonsils or adenoids removed?
Age:
* Do you have any special problems not listed?
Explain:
* Have you ever been advised by your physician to take an antibiotic prior to any dental treatment?
If yes, antibiotic name and method:
Pharmacy:
Do you use tobacco (smoking or chewing)?
Your approximate height?
Your approximate weight?

WOMEN

Are You pregnant or considering pregnancy during the next two years?
Are you nursing?
Are you currently taking medication for birth control?

DO YOU HAVE, OR HAVE HOU EVER HAD ANY OF THE FOLLOWING?
Tuberculosis?
Diabetes?
ADD:
Endocarditis:
Respiratory lung disease:
Kidney trouble?
Heart condition:
High blood pressure?
Liver disease?
Pacemaker:
Low blood pressure:
Psychiatric treatment:
Heart angina?
* Hepatitis:
Type:
Drug addiction:
Heart attack?
Venereal disease:
Headaches:
Mitral valve prolapse:
Herpes (oral cold sore):
Earaches:
Congenital heart disease?
Blood disorders bleeding problem:
Jaw clicking?
Artificial heart valves?
Inflammatory rheuamatism:
Allergies:
* Heart surgery:
Date:
Ulcers:
Allergy to metal:
Heart murmur?
Stroke:
Allergies to latex?
Rheumatic fever?
Anemia?
Arteriosclerosis?
Jaw pain:
Arthritis/Osteoporosis/Bisphosphonates?
Asthma?
Tonsillitis:
Prosthetic (artificial) joints?
Epilepsy?
Emotional problems?
X-Ray/Radiation (cancer) therapy:
Glaucoma:
AIDS or H.I.V. positive?
Fainting spells: