Patient Information Form
Title:
Mrs.
Mr.
Dr.
Ms.
First Name:
Middle Initial:
Last Name:
Nickname:
Date of Birth:
Gender:
Male
Female
Other
Cell/Home Phone #:
Email:
School
(if applicable)
:
Grade
(if applicable)
:
Address:
City:
State:
Zip:
Employer
(if applicable)
:
Occupation
(if applicable)
Work Phone #:
*
Does patient have Orthodontic Insurance Coverage?
Yes
No
(If yes, please bring your insurance card to your appointment.)
Please fill in the following Insurance fields if you answered Yes above.
Insurance Company Name:
Policy Holder's Name:
Subscriber ID:
Subscriber Date of Birth:
Group Name:
Group Number:
List any hobbies or sports:
Patient's general dentist:
Date of last dental visit:
How did you learn about our practice or whom may we thank for referring you?
Family History
List names of family members treated by Dr. LeCompte & Beauchamp:
Is the patient adopted?
Yes
No
(If yes, skip to Medical Information Section.)
Has either biological parent had braces?
Yes
No
Patient's height:
Father's height:
Mother's height:
Person Responsible for Account
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
City:
State:
Zip:
Cell/Home Phone #:
Email:
Employer:
Occupation:
Work Phone #:
Medical Information
Family Physician:
Physician's Phone #:
Select 'Yes' for any of the following for which the patient has been diagnosed:
Anemia
Yes
No
Arthritis
Yes
No
Artificial heart valves
Yes
No
Artificial joints, pins, etc.
Yes
No
Asthma
Yes
No
Abnormal bleeding
Yes
No
Blood disease
Yes
No
Cancer
Yes
No
Chemical dependency
Yes
No
Chemotherapy
Yes
No
Circulatory problems
Yes
No
Congenital heart lesions
Yes
No
Diabetes
Yes
No
Epilepsy
Yes
No
Fainting
Yes
No
Headaches
Yes
No
Heart murmur
Yes
No
Heart problems
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
High blood pressure
Yes
No
HIV AIDS
Yes
No
Jaw pain
Yes
No
Kidney disease
Yes
No
Liver disease
Yes
No
Mitral valve prolapse
Yes
No
Pacemaker
Yes
No
Radiation treatment
Yes
No
Respiratory disease
Yes
No
Rheumatic fever
Yes
No
Scarlet fever
Yes
No
Stroke
Yes
No
Thyroid problems
Yes
No
Tobacco use
Yes
No
Tonsilitis
Yes
No
Tuberculosis
Yes
No
Ulcer
Yes
No
Other:
Have patient's tonsils and/or adenoids been removed?
Yes
No
Does the Patient need to premedicate prior to dental procedures?
Yes
No
List any medications the patient is currently taking and the correlating diagnosis:
List any allergies:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Thumb / finger sucking
Yes
No
Injury to face or teeth
Yes
No
Speech problems / therapy
Yes
No
Grinding / clenching of teeth
Yes
No
Missing or extra teeth
Yes
No
Dental anxiety
Yes
No
History of periodontal disease
Yes
No
History of wearing a mouthguard at night
Yes
No
Popping / clicking in jaw joint(s)
Yes
No
Children Only
Has the patient reached puberty?
Yes
No
Date menstruation began (females):
Has patient's voice changed (males)?
Yes
No
Has the patient grown in the past year or has their shoe size changed recently?
Yes
No