Patient Information
First Name:
MI:
Last Name:
Name You Prefer to Go By:
Gender:
Male
Female
Address:
City:
State:
Zip:
Birthdate:
Age:
Is patient adopted:
No
Yes
Social Security # (only needed if presenting dental insurance):
Home/Cell Phone:
Work Phone:
Secondary Phone:
Email:
Sports and Interests:
How did you hear about us/Whom may we thank for referring you to our practice?
Reason for Seeking Orthodontic Treatment:
If patient is an adult - Employer:
Do you have orthodontic insurance?
No
Yes
Insurance Company:
Subscriber:
If patient is a child, please list names and birthdates of siblings:
Names of family members we have treated:
Parent Information
(if patient is a minor)
Mother's Information
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address (if different from above):
City:
State:
Zip:
How long at address?
Home Phone:
Work Phone #:
2nd/Cell Phone:
Email:
Birthdate:
Social Security # (for insurance purposes only):
Employer:
Occupation:
Length of Employment:
Father's Information
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address (if different from above):
City:
State:
Zip:
How long at address?
Home Phone:
Work Phone #:
2nd/Cell Phone:
Email:
Birthdate:
Social Security # (for insurance purposes only):
Employer:
Occupation:
Length of Employment:
Who is responsible for payment:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Home Phone:
Cell Phone:
Medical History
Has the patient ever been treated for any of the following:
Diabetes
No
Yes
Anemia
No
Yes
Prolonged Bleeding
No
Yes
Pneumonia
No
Yes
Epilepsy
No
Yes
Liver Involvement
No
Yes
Heart Murmur
No
Yes
Asthma
No
Yes
Fainting/Dizziness
No
Yes
Rheumatic Fever
No
Yes
Kidney Involvement
No
Yes
Nervous Disorders
No
Yes
Mitral Valve Prolapse
No
Yes
Latex Sensitivity
No
Yes
HIV Positive
No
Yes
Premed for Heart Condition
No
Yes
Nickel Sensitivity
No
Yes
Tuberculosis
No
Yes
Bone Disorder
No
Yes
Endocrine/Thyroid
No
Yes
Birth Defects/Hereditary Problems
No
Yes
Is the patient in good health?
No
Yes
Does the patient smoke?
No
Yes
Does the patient have a history of major illness?
No
Yes
Can the patient breathe comfortably with the lips closed?
No
Yes
Have Tonsils and or adenoids been removed?
No
Yes
What Age:
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 a teacher commented that your child appears sleepy during the day?
No
Yes
Does your child occasionally wet the bed?
No
Yes
While sleeping, does your child...
Snore more than half the time?
No
Yes
Have trouble breathing or struggle to breathe?
No
Yes
Yes
Have heavy or "loud" breathing?
No
Yes
Have you ever seen your child stop breathing during the night?
No
Yes
List any drugs or medications now being taken. Give Reasons:
List any drug allergies or sensitivities:
Patient's Physician:
Phone #:
Last Seen:
Dental History
Patient's Dentist:
Phone #:
Date of Last Check-up:
Is there any dental work (cavities or fillings) that still need to be done?
No
Yes
Have there been any injuries to face, mouth, or teeth?
No
Yes
Has the patient ever sucked a thumb or finger?
No
Yes
Until What Age:
Does the patient have any clicking or discomfort in jaw joints near ears?
No
Yes
Have you been informed of any missing or extra permanent teeth?
No
Yes
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, who treated?
If so, when?
Does the patient clench or grind his or her teeth?
No
Yes
Is the patient especially apprehensive toward dental visits?
No
Yes
Does the patient have any congenital abnormalities?
No
Yes
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/HIPAA NOTIFICATION
Bruce Podhouser & Jameson Hardy
Diplomats of the American Board of Orthodontics
152 U.S. Route One, Scarborough, ME 04074 (207) 885-4850
92 Pine Street, North Conway, NH 03860 (603) 356-8940
**You May Refuse to Sign This Acknowledgement**
I have received a copy of this office’s Notice of Privacy Practices. In addition, you give us permission to give PPI (Personal Protected Info) through texts in regards to your child’s treatment on the phone numbers you have provided. If there is anyone else we can discuss treatment with, please list them below:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Patient Name:
Signature:
Date:
E-Signature (Parent's signature if minor):
Date: