Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
How do you prefer to receive appointment reminders?
Phone
Text
E-mail
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
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:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Emergency Contact Information
Name
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Main Phone:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the patient have apprehension about dental care?
No
Yes
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.
Abnormal swallowing (tongue thrust)?
No
Yes
Bad taste or mouth odor?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Wear a nightguard?
No
Yes
Discomfort from teeth or gums?
No
Yes
Floss teeth daily?
No
Yes
Frequent sore throats?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Numerous fillings?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Bleeding gums?
No
Yes
Previous root canal therapy?
No
Yes
Problems with food trapped between teeth?
No
Yes
Snores during sleep?
No
Yes
Family history of sleep apnea?
No
Yes
Speech problems or therapy?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Teeth that irritate tongue, cheek, lip, etc?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Does your bite feel uncomfortable or unusual?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Codeine or other narcotics?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Penicillin or other antibiotics?
No
Yes
Metal allergy? If yes, please explain.
No
Yes
Other allergies or sensitivities? If yes, please explain.
No
Yes
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Chronic fatigue?
No
Yes
Diabetes?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Tonsils or adenoids removed?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Arteriosclerosis, Tuberculosis, lung disease, Pneumonia, cancer, cancer in family history, radiation treatment, thyroid or endocrine problems, stomach ulcer, hyperacidity, hormone therapy, nervous disorders? If yes, please explain.
No
Yes
Bone disorders, bone los, seizures, epilepsy, neurological disease, treated for emotional problems, asthma, respiratory problems, emphysema, persistent swollen neck glands, sexually transmitted disease, low blood pressure, or persistent cough? If yes, please explain.
No
Yes
Heart attack, stroke, congenital heart defect, heart disease, heart murmur, damaged or artificial heart valves? If yes, please explain.
No
Yes
Hemophilia, high blood pressure, hypertension, anemia, blood disorder, prolonged bleeding, transfusión, HIV or AIDS? If yes, plkease explain.
No
Yes
Kidney disease, liver disease, jaundice, or hepatitis? If yes, please explain.
No
Yes
Tonsils enlarged or sinus trouble? If yes, please explain.
No
Yes
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Has either biological parent ever had orthodontic treatment?
Don't know
No
Yes
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.
I agree to allow my photographs and x-rays to be used for educational purposes
I agree to allow my photo to be used for social media or in house marketing purposes.
I have reviewed a copy of the Khara Orthodontics
Notice of Privacy Practices
.