Patient Information Form
Title:
Mrs.
Mr.
Dr.
Ms.
First Name:
Middle Initial:
Last Name:
Nickname:
Date of Birth:
Gender:
Male
Female
Other
Cell 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:
Insurance Company's Phone:
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:
Do you give our office permission to obtain and/or share records and treatment information with your general dentist?
No
Yes
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:
Abnormal bleeding
Yes
ADD/ADHD
Yes
Anemia
Yes
Arthritis
Yes
Artificial heart valves
Yes
Artificial joints, pins, etc.
Yes
Asthma
Yes
Autism
Yes
Blood disease
Yes
Cancer
Yes
Chemical dependency
Yes
Chemotherapy
Yes
Circulatory problems
Yes
Congenital heart lesions
Yes
Diabetes
Yes
Epilepsy
Yes
Fainting
Yes
Headaches
Yes
Heart murmur
Yes
Heart problems
Yes
Hemophilia
Yes
Hepatitis
Yes
High blood pressure
Yes
HIV AIDS
Yes
Jaw pain
Yes
Kidney disease
Yes
Liver disease
Yes
Mitral valve prolapse
Yes
Pacemaker
Yes
Radiation treatment
Yes
Respiratory disease
Yes
Rheumatic fever
Yes
Scarlet fever
Yes
Sensory Issues
Yes
Stroke
Yes
Thyroid problems
Yes
Tobacco use
Yes
Tonsilitis
Yes
Tuberculosis
Yes
Ulcer
Yes
Other:
Have patient's tonsils and/or adenoids been removed?
Yes
Does the Patient need to premedicate prior to dental procedures?
Yes
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.
Thumb / finger sucking
Yes
Injury to face or teeth
Yes
Speech problems / therapy
Yes
Grinding / clenching of teeth
Yes
Missing or extra teeth
Yes
Dental anxiety
Yes
History of periodontal disease
Yes
History of wearing a mouthguard at night
Yes
Popping / clicking in jaw joint(s)
Yes
Does the patient breathe through their mouth?
Yes
Does the patient snore?
Yes
Does the patient sleep with their mouth open?
Yes
Has the patient been diagnosed with sleep apnea?
Yes
Does the patient use a CPAP machine?
Yes
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