Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Male
Female
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Village/Subdivision:
Email:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Name of school:
Grade:
Special interests, sports, or hobbies:
Patient's Dentist:
Phone #: (10 digit number)
Please list any other family members we have treated:
Whom can we thank for this referral?
Dentist:
Friends:
Friends:
Friends:
Other:
Name of person accompanying child to appointment:
Relationship:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Siblings
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Name:
Birthdate:
Gender:
Male
Female
Guardian 1
First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (please update if different)
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Email:
Employer:
Guardian 2
First Name:
Middle Initial:
Last Name:
Birthdate:
Address: (if different)
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone: (10 digit number)
Secondary Phone: (10 digit number)
Email:
Employer:
Person Responsible for Financials
Who is responsible for account:
Guardian 1
Guardian 2
Other
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip: (5 digits)
Primary Phone: (10 digit number)
Cell: (10 digit number)
Work:
Email:
Social Security #:
Employer:
Primary Dental Insurance Information
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:
Secondary Dental Insurance Information
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured's Employer:
Insured's Name:
Insured's Birthdate:
Relationship to Patient:
Group #:
Member ID# or SS#:
Medical History
Select here if all answers BELOW are
NO
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Heart Murmur/Congenital Defect
No
Yes
Diabetes
No
Yes
Rheumatic Fever
No
Yes
Cancer
No
Yes
HIV/AIDS
No
Yes
Hemophilia
No
Yes
Blood Transfusions
No
Yes
Asthma
No
Yes
Hepatitis
No
Yes
Tuberculosis
No
Yes
Heart Problems
No
Yes
Sinus Problems
No
Yes
Hypertension/High Blood Pressure
No
Yes
Convulsions/Epilepsy
No
Yes
Abdominal Bleeding
No
Yes
Hearing Impairment
No
Yes
Operations/Stays in a Hospital
No
Yes
Kidney/Liver Problems
No
Yes
Handicaps/Disabilities
No
Yes
Allergies to Drugs, Metals, or Foods
No
Yes
Antibiotics Prior to Dental Treatment
No
Yes
Other Medical Problems
No
Yes
Currently Taking Medication
No
Yes
*
Currently Pregnant
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Dental History
Select here if all answers BELOW are
NO
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Injuries to Face/Teeth
No
Yes
Other Orthodontic Treatment
No
Yes
Pain/Noises in the Jaw Joint (TMJ)
No
Yes
Root Resorption
No
Yes
Periodontal Disease
No
Yes
Unfavorable Dental Experience
No
Yes
Missing Teeth
No
Yes
Extra Teeth
No
Yes
Finger Sucking
No
Yes
Tongue Thrusting
No
Yes
Speech Problems
No
Yes
Mouth Breathing
No
Yes
Gums Bleed
No
Yes
Grind Teeth
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
What do you see as the main problem with your teeth?
Emergency Information
Who should we contact in the event of an emergency?
Phone: (10 digit number)
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Spouse
Stepfather
Stepmother
Other
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.