Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
*
Sex:
Male
Female
Preferred Pronouns
She/Her
He/Him
They/Them
Address:
City:
State:
Zip:
Primary Phone:
Social Security #:
If patient is a minor, give parent's/guardian's name:
If patient is a minor, please list names and birthdates of siblings.
Family dentist:
When last seen:
Is any dental work pending?
No
Yes
Please describe
Whom may we thank for referring you to our office?
Please rank order the following items in order of your priority (1=most important, 4=least important)
*
Cost of treatment
*
Quality of orthodontic result
*
Esthetic treatment options
*
Length of treatment
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Nickname:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Residence Address:
City:
State:
Zip:
Rent or own?
Rent
Own
Mailing Address:
City:
State:
Zip:
How long at this address?
Previous address (if less than 3 years)
Email:
Home Phone:
Work Phone:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Employer:
Occupation:
Length of Employment:
Social Security Number:
Spouse's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Insured's Name:
Member ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Insured's Name:
Member ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Emergency Contact Information
Name:
Address:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Medical History
Main concerns
regarding the jaws and teeth
Patient's current
physical
health
Good
Excellent
Fair
Poor
Patient's current
mental
health
All
current medications
taken by patient
Please provide explanation for any "yes" answers
Blood disorders
No
Yes
Circulatory Problems
No
Yes
Immune Problems
No
Yes
Airway Problems
No
Yes
Allergies
No
Yes
Communicable Disease
No
Yes
Dental History
Please provide explanation for any "yes" answers
Significant Injury
No
Yes
Grind/clench teeth
No
Yes
Difficulty chewing
No
Yes
Pain/clicking
No
Yes
TMJ disorder
No
Yes
Orthodontic History
Please provide explanation for any "yes" answers
Previous orthodontic treatment
No
Yes
Concerns about orthodontic treatment
No
Yes
Oral habits
No
Yes
Speech disorder/therapy
No
Yes
Any additional information the doctor might find helpful
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.
Signature
Date: