Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Pt. Cell Phone:
Pt. Email:
Birthdate:
Social Security #:
If patient is a minor, give parent's or guardian's name:
Please list any Hobbies the patient has:
Please list any Sports the patient plays:
Please list any Interests the patient has:
How did you hear about our office/Whom may we thank for referring you to our office?
Confidential Responsible Party Information
Patient or parent completing form
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Mailing Address:
City:
State:
Zip:
Residence Address (if different from both):
City:
State:
Zip:
Home Phone:
How long at this address:
Do you own or rent?
Own
Rent
Previous Address (if above shorter than 3 years):
City:
State:
Zip:
Cell Phone:
Email:
Work Phone:
Social Security Number:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
SPOUSE'S First Name:
Middle Initial:
Last Name:
Cell Phone:
Email:
Work Phone:
Social Security Number:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
Any additional parent or guardian information you would like to add:
Insurance Information
Policy Holder's Name:
Policy Holder's Employer:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Soc. Sec. #:
Insruance ID (if different than SSN):
Group No./Union Local No.
Do you have dual dental coverage?
Yes
No
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Employer:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Soc. Sec. #:
Insruance ID (if different than SSN):
Group No./Union Local No.
Any additional insurance information you would like to add:
Emergency Contact Information
Nearest relative not living with you:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Please list the names of any other dental professionals seen in the last 6 months:
Please select specialty:
Endodontist
Oral Surgeon
Periodontist
Prosthodontist
Other
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
What is the patient's main orthodontic concern?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Apprehensive about dental care?
Yes
No
Brush teeth daily?
Yes
No
Clench or grind teeth?
Yes
No
Discomfort from teeth or gums?
Yes
No
Floss teeth daily?
Yes
No
Fluoride treatments?
Yes
No
Frequent canker sores?
Yes
No
Frequently chew gum?
Yes
No
Frequent headaches?
Yes
No
Frequent sore throats?
Yes
No
Injury to face, jaw, teeth, or mouth?
Yes
No
Missing or extra permanent teeth?
Yes
No
Mouth breathing?
Yes
No
Neck or shoulder pain?
Yes
No
Oral habits (thumb or finger sucking, lip or nail biting)?
Yes
No
Pain, tenderness, or noise in either jaw?
Yes
No
Previous periodontal treatment?
Yes
No
Requires premedication?
Yes
No
Snores during sleep?
Yes
No
Speech problems or therapy?
Yes
No
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia or blood disorder?
Yes
No
Arthritis or joint problems?
Yes
No
Asthma?
Yes
No
Bisphosphonates (Fosamax, Boniva)?
Yes
No
Bone disorders or loss?
Yes
No
Cancer?
Yes
No
Cancer in family history?
Yes
No
Diabetes?
Yes
No
Emotional problems treatment?
Yes
No
Endocrine problems?
Yes
No
Growth problems?
Yes
No
Handicaps or disabilities?
Yes
No
Heart attack or stroke?
Yes
No
Heart defect (congenital)?
Yes
No
Heart disease?
Yes
No
Heart murmur?
Yes
No
Hemophilia?
Yes
No
Hepatitis?
Yes
No
High blood pressure or hypertension?
Yes
No
HIV or AIDS?
Yes
No
Hormone therapy?
Yes
No
Ever been hospitalized?
Yes
No
Kidney disease?
Yes
No
Latex or Metal Allergy?
Yes
No
Liver disease, jaundice, or hepatitis?
Yes
No
Nervous disorders?
Yes
No
Pneumonia?
Yes
No
Prolonged bleeding or transfusion?
Yes
No
Radiation treatment?
Yes
No
Rheumatic fever?
Yes
No
Seizures, epilepsy, or neurological disease?
Yes
No
Tonsils or adenoids removed?
Yes
No
Tuberculosis or lung disease?
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
Yes
No
If patient is a girl, has menstruation begun?
Yes
No
If patient is a boy, has their voice changed or have facial hair?
Yes
No
Has the patient grown in the past year or has their shoe size changed recently?
Yes
No
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
I understand that where appropriate, credit bureau reports may be obtained.
Signature:
By typing my name above I am electronically signing this form.