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:
Village/Subdivision:
*
Email:
*
Primary Phone:
Secondary Phone:
Name of school:
Grade:
Special interests, sports, or hobbies:
Patient's Dentist:
Phone #:
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:
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone:
Secondary Phone:
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:
Relationship to Patient:
Mother
Father
Guardian
Grandparent
Other
Marital Status:
Married
Single
Widowed
Divorced
Separated
Social Security #:
Primary Phone:
Secondary Phone:
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:
*
Primary Phone:
Cell:
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
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
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:
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.