Confidential Patient Information
*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell 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?
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
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:
Relationship to Patient:
Select
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.:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Medical History
Name of Family Physician:
Date of last visit to physician:
Are there any medical specialists you see regularly?
No
Yes
Specialty:
Date of last complete physical exam:
Examing doctor:
Pharmacy: Name:
Phone:
Has this patient been advised by a physician that they require an
antibiotic prior to dental treatment
?
No
Yes
If yes, Antibiotic:
How is antibiotic given?
This patient's general health at this time is:
Good
Fair
Poor
Comment:
Is this patient presently under the care of a physician?
No
Yes
For what?
Is this patient presently taking medications?
No
Yes
If yes, which medications:
Has this patient had tonsils or adenoids removed?
No
Yes
Tonsils (on date)
Adenoids (on date)
Does this patient have a
Chronic Illness
?
No
Yes
Comment:
Has this patient ever had a serious illness?
No
Yes
Comment:
Has this patient ever been
Hospitalized
?
No
Yes
For what?
Has this patient ever had a substance abuse problem?
No
Yes
What substance(s)?
Has this patient ever had emotional problems?
No
Yes
Describe?
Does this patient have any handicaps/disabilities?
No
Yes
Describe?
Is this patient allergic to antibiotics (penicillin, etc)?
No
Yes
If yes, which medications:
Does this patient have anesthetic reactions? If yes, Local or General?
No
Yes
General
Local
Is this patient allergic to anything else? If yes, what?
No
Yes
Sulfa Drugs
Aspirin
Ibuprofen
Environmental
Metals
Plastics
Latex
Comments:
Does this patient now have, or ever had any of the following problems
No
Yes
Rheumatic Fever
No
Yes
Hepatitis (type?)
No
Yes
Diabetes
No
Yes
Endocarditis
No
Yes
AIDS or HIV Positive
No
Yes
Epilepsy
No
Yes
Heart Condition
No
Yes
Tuberculosis
No
Yes
Stroke
No
Yes
Heart Pacemaker
No
Yes
Lived with tuberculin person
No
Yes
Stomach Ulcers
No
Yes
Respiratory Lung Disease
No
Yes
Tonsillitis
No
Yes
Asthma
No
Yes
Headaches
No
Yes
Venereal Disease
No
Yes
Earaches
No
Yes
Herpes (Oral Cold Sores)
No
Yes
Jaw Pain
No
Yes
Inflammatory Rheumatism
No
Yes
Jaw Clicking (Noise)
No
Yes
Arthritis
No
Yes
X-Ray (radiation) cancer therapy
No
Yes
High Blood Pressure
No
Yes
Glaucoma
No
Yes
Low Blood Pressure
No
Yes
Fainting Spells
No
Yes
Blood Disorders/Bleeding Problems
No
Yes
Kidney Trouble
No
Yes
Anemia
No
Yes
Liver Disease
Please comment on any YES responses:
Does this patient have any other medical problems not listed?
No
Yes
Patient's Growth History
What is this patient's height?
Child's present age:
Is child adopted?
No
Yes
Any recent signs of increased growth?
No
Yes
If a
BOY
, has his voice changed?
No
Yes
If a
GIRL
, has she started menstruation?
No
Yes
MOTHER'S
present height:
FATHER'S
present height:
Dental History
Name of Family Dentist:
Date of last dental visit:
How many times a day do you
BRUSH
?
0
1
2
3+
How many times a day do you
FLOSS
?
0
1
2+
Has this patient been examined by another orthodontist?
No
Yes
Date:
Name of orthodontist:
Has this patient ever had
orthodontic treatment
(braces)?
No
Yes
Date:
Name of dentist:
Has this patient been treated for jaw joint (TMJ) problems?
No
Yes
Date:
Name of dentist:
Has this patient been treated for
gum
disease?
No
Yes
If yes, what kind of treatment?
Has this patient had
root canal
treatment?
No
Yes
If yes, which teeth?
Has this patient had
other
dental specialist treatment?
No
Yes
If yes, what?
Does this patient have any oral habits?
No
Yes
If yes, which?
Thumb Sucking
Finger Sucking
Lip Biting
Tongue Thrusting
Speech Problems
Mouth Breathing
Comments:
Does this patient have any
TMJ
(jaw joint)
Symptoms
?
No
Yes
If yes, what symptoms?
Grinding
Clenching
Jaw Joint Noises
Headaches/Neckaches
Jaw Joint Pain
Facial or Ear Pain
Locking or difficulty moving Jaws
Dental/Facial Trauma
Arthritis
Comments?
Does this patient have any
Missing Permanent Teeth
?
No
Yes
Comment:
Does this patient have any
Extra Permanent Teeth
?
No
Yes
Comment:
Does this patient typically have
bleeding gums
?
No
Yes
Comment:
Does this patient have
sores, lumps, or irritated tissue
in the mouth?
No
Yes
Comment:
Has this patient had any
injuries
to his/her teeth?
No
Yes
Comment:
Has this patient had any
injuries
to his/her face, jaws, or mouth??
No
Yes
Comment:
Has this patient been informed of any
Speech Problems
?
No
Yes
Comment:
Are there any other comments about this patient's dental history?
No
Yes
Comment:
Patient and Family Concerns
What are this patient's concerns about his/her teeth?
Appearance of Teeth
Oral Function
Crowding/Spacing
Flared Teeth
Other concerns or comments:
Is this patient anxious about having orthodontic treatment?
No
Yes
Comment:
Does the family dentist have any concerns about this patient's teeth?
No
Yes
Comment:
Do any other family members have concerns about this patient's teeth?
No
Yes
Comment:
Family History of Orthodontic Treatment
Have any members of your family received orthodontic treatment?
Mother
Yes
No
If yes, Dentist or Orthodontist?
Dentist
Orthodontist
Were you satisfied with the result?
Yes
No*
Father
Yes
No
If yes, Dentist or Orthodontist?
Dentist
Orthodontist
Were you satisfied with the result?
Yes
No*
Sister
Yes
No
If yes, Dentist or Orthodontist?
Dentist
Orthodontist
Were you satisfied with the result?
Yes
No*
Brother
Yes
No
If yes, Dentist or Orthodontist?
Dentist
Orthodontist
Were you satisfied with the result?
Yes
No*
Child
Yes
No
If yes, Dentist or Orthodontist?
Dentist
Orthodontist
Were you satisfied with the result?
Yes
No*
* If no, Comment:
If your dentist has taken new
full mouth
or
panoramic x-rays
in the past six months,
please bring them with you to the exam
.
If you have had
orthodontic records
taken in the past six months,
please bring them with you to the exam
.
If you are currently wearing an
orthodontic appliance
or
Bite Splint
(night guard),
please bring it with you to the exam
.
Is there any other medical or dental condition that we should know about?
No
Yes
I the undersigned have completed this medical and dental health history and certify that the preceding information is true and correct. This practice cannot be held responsible for any problems arising out of inadequate information not disclosed here. If there are any future changes in this information, I will inform this practice of these changes.