Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Home/Cell Phone:
Address:
City:
State:
Zip:
Email:
My Status:
Single
Married
Widowed
Separated
Divorced
Emergency Contact:
Phone:
Occupation:
Business Phone:
Other Family Members treated?
What are your interests (i.e. sports, hobbies, or musical instruments)?
Do you have dental insurance?
Please present dental insurance card(s) to the front desk
No
Yes
Name of Subscriber:
Birthday of Subscriber:
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
Name of Subscriber:
Birthday of Subscriber:
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
How Did You Hear About Us?
Please check all the ways you heard about us and select the main reason. Thank you!
Direct Referrals:
Dentist/Hygienist
Family Member
Friends/Co-Workers
Our Staff
Community:
Location of Office
Building Sign
Office Incentives (patient rewards, contests)
Sports Teams/Sponsorship
Online:
Website
Facebook/Instagram
Google
Yelp
Miscellaneous:
Insurance Company
Other
Main Reason:
Dentist/Hygienist
Family Member
Friends/Co-Workers
Our Staff
Website
Facebook/Instagram
Google
Yelp
Location of Office
Building Sign
Office Incentives
Sports Teams/Sponsorship
Insurance Company
Other
Medical History
Physician Name:
Do you feel as though you are in good health?
No
Yes
If no, please explain:
Do you smoke?
Yes
No
Please select 'Yes' for any of the following for which you have been diagnosed or treated:
Diabetes
No
Yes
Asthma
No
Yes
Allergies
No
Yes
Rheumatic Fever
No
Yes
Heart Trouble
No
Yes
Epilepsy
No
Yes
Cancer
No
Yes
Bleeding Disorders
No
Yes
Depression
No
Yes
Anemia
No
Yes
Seizures
No
Yes
ADD/ADHD
No
Yes
HIV/AIDS
No
Yes
Dizziness/Fainting
No
Yes
Migraines
No
Yes
Hip/Joint Replacement
No
Yes
If any of the above medical questions were answered 'Yes', please explain:
Have your tonsils and adenoids been removed?
No
Yes
If so, at what age?
Are you currently or have you taken bisphosphonate drugs such as Zometa, Fosamax, Boniva, etc. for bone disorders or cancer?
No
Yes
If yes, please explain:
Please list any drugs or medications you are taking:
Latex Allergy?
No
Yes
Do you take antibiotic pre-medication before any dental procedures?
No
Yes
Female Patients:
Are you pregnant or anticipating becoming pregnant?
No
Yes
Any other medical issues not addressed above?
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during orthodontic treatment?
Dental History
Dentist Name:
Date of Last Checkup/Cleaning:
How often do you brush your teeth?
How often do you floss?
Have you ever been treated for periodontal disease or have a history of periodontal problems?
No
Yes
If yes, please explain:
Have any teeth been injured due to accidents or falls?
No
Yes
If yes, please explain:
Have you had any severe head or face injuries?
No
Yes
If yes, please explain:
Have you experienced any sensitivity or discomfort from:
Gums
Teeth
Bite
Please explain:
Clench or grind teeth?
No
Yes
Mouth breather?
No
Yes
Have you had any previous orthodontic work?
No
Yes
If yes, at what age (approximate)?
By whom?
Have you had any primary (baby) or permanent teeth removed?
No
Yes
Clicking or popping in your jaw joints?
No
Yes
Describe:
Pain in your jaw joints?
No
Yes
Describe:
Have you ever been treated for "TMJ" or "TMD" problems?
No
Yes
Describe:
Any other dental issues not addressed above?
Smile Analysis
What is your primary concern?
Do you feel the teeth are:
Spaced apart?
Crowded/Overlapped?
Too far forward?
Too far backward?
"Gummy" smile?
Inadequate teeth shown when smiling?
Are there any other orthodontic issues not listed above that you wish to discuss?
I have read and understand the above questions.
I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.