Confidential Patient Information
Date:
Whom may we thank for referring you to our practice?
First Name:
Middle Initial:
Last Name:
Sex:
Male
Female
Other
Age:
Birthdate:
Prefers to be called:
Phone #:
Cell #:
Email:
Address:
City:
State:
Zip:
Financial Party Information
Employed By:
Occupation:
Work Phone:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
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:
Subscriber/Member ID
Ortho Coverage:
No
Yes
Insured's Name:
SSN #:
Birthdate:
Secondary Insurance Co:
Group Number:
Phone Number:
Subscriber/Member ID
Ortho Coverage:
No
Yes
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?
No
Yes
Have you had or do you presently have any of the following habits?
Thumb or finger sucking
Lip biting
Snoring
Grinding of teeth at night
Mouth breathing
Have you been informed of any missing or extra permanent teeth?
No
Yes
Are you aware of any sores, lumps or irritated areas in the mouth?
No
Yes
*
Has an orthodontist been consulted previously?
No
Yes
If so, who?
When?
Have you ever been treated for:
Bad bite
TMJ
Periodontal disease
If so, by whom:
Do you have any speech problems?
No
Yes
Are you concerned or anxious about orthodotic treatment?
No
Yes
Are you concerned about the appearance of your teeth?
No
Yes
*
Is there anything you would like to change about your smile?
No
Yes
If so, what?
What aspect of dental treatment are you most concerned with?
Quality
Cost
Most concerned with discomfort
Most concerned with time
Reason for consultation (chief concern):
Has there ever been any orthodontic treatment for any other member of your family:
No
Yes
Were they satisfied with the results:
No
Yes
Dr. who treated children:
Dr. who treated Spouse:
Dr. who treated other family:
Medical History
Is your general health good at this time?
No
Yes
Is the patient now under the care of a physician at this time? If so, please explain:
No
Yes
*
Are you taking any medication?
No
Yes
If so, what:
*
Are you allergic to any medication? (Penicillin, Sulfa, etc.
No
Yes
If so, what:
Have you ever had a serious illness or hospitalization? If so, what for?
No
Yes
*
Have you had your tonsils or adenoids removed?
No
Yes
Age:
*
Do you have any special problems not listed?
No
Yes
Explain:
*
Have you ever been advised by your physician to take an antibiotic prior to any dental treatment?
No
Yes
If yes, antibiotic name and method:
Pharmacy:
Do you use tobacco (smoking or chewing)?
No
Yes
Your approximate height?
Your approximate weight?
WOMEN
Are You pregnant or considering pregnancy during the next two years?
No
Yes
Are you nursing?
No
Yes
Are you currently taking medication for birth control?
No
Yes
DO YOU HAVE, OR HAVE HOU EVER HAD ANY OF THE FOLLOWING?
Tuberculosis?
No
Yes
Diabetes?
No
Yes
ADD:
No
Yes
Endocarditis:
No
Yes
Respiratory lung disease:
No
Yes
Kidney trouble?
No
Yes
Heart condition:
No
Yes
High blood pressure?
No
Yes
Liver disease?
No
Yes
Pacemaker:
No
Yes
Low blood pressure:
No
Yes
Psychiatric treatment:
No
Yes
Heart angina?
No
Yes
*
Hepatitis:
No
Yes
Type:
Drug addiction:
No
Yes
Heart attack?
No
Yes
Venereal disease:
No
Yes
Headaches:
No
Yes
Mitral valve prolapse:
No
Yes
Herpes (oral cold sore):
No
Yes
Earaches:
No
Yes
Congenital heart disease?
No
Yes
Blood disorders bleeding problem:
No
Yes
Jaw clicking?
No
Yes
Artificial heart valves?
No
Yes
Inflammatory rheuamatism:
No
Yes
Allergies:
No
Yes
*
Heart surgery:
No
Yes
Date:
Ulcers:
No
Yes
Allergy to metal:
No
Yes
Heart murmur?
No
Yes
Stroke:
No
Yes
Allergies to latex?
No
Yes
Rheumatic fever?
No
Yes
Anemia?
No
Yes
Arteriosclerosis?
No
Yes
Jaw pain:
No
Yes
Arthritis/Osteoporosis/Bisphosphonates?
No
Yes
Asthma?
No
Yes
Tonsillitis:
No
Yes
Prosthetic (artificial) joints?
No
Yes
Epilepsy?
No
Yes
Emotional problems?
No
Yes
X-Ray/Radiation (cancer) therapy:
No
Yes
Glaucoma:
No
Yes
AIDS or H.I.V. positive?
No
Yes
Fainting spells:
No
Yes
*
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthondist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.