Confidential Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
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Address:
*
City:
*
State:
*
Zip:
*
Phone Type:
Home
Cell
Work
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Phone:
Phone Type:
Home
Cell
Work
Phone:
*
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
*
How did you hear about our practice? (Dentist, Friend, Sign, Internet - List any that apply)
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
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First Name:
Middle Initial:
*
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
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Birthdate:
*
Address:
*
City:
*
State:
*
Zip:
How long at this address?
Previous Address (less than 3 years)
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Phone Type:
Home
Cell
Work
*
Phone:
Phone Type:
Home
Cell
Work
Phone:
Email:
Social Security #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Do you have dental coverage?
No
Yes
(IF YES, REQUIRED FIELDS AS NOTED BELOW)
*
Policy Holder's Name:
*
Policy Holder's DOB:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
*
Insurance Company:
*
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
*
Policy Holder's Name:
*
Policy Holder's DOB:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
*
Insurance Company:
*
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
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Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
*
Does the Patient need to premedicate prior to dental visit?
No
Yes
Does the patient brush daily?
No
Yes
Does the patient floss daily?
No
Yes
What is the patient's main orthodontic concern?
Please check any of the following that apply:
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste/mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above conditions were selected, please explain:
Have you had a TMJ screening?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above conditions were selected, please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
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Has there been any change in the patient's general health within the last year?
No
Yes
*
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
*
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies or sensitivities that the patient may have:
Does the patient have any of the following conditions? Check all that apply.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Thyroid / Endocrine Problems
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Sexually transmitted disease
Take Bisphosphonates (Fosamax, Boniva)
If any of the above conditions were selected, please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.