Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Gender:
Male
Female
Other
Birthdate:
Age:
Address:
City:
State:
Zip:
Main Phone:
Dentist:
Physician:
Whom may we thank for referring you to our practice?
What questions would you like answered today?
Person(s) responsible for payment:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Complete For A Child/Teen Patient
School:
Grade:
Musical Instrument:
Sports:
Hobbies/Interests
Parent/Guardian:
Middle Initial:
Last Name:
Cell Phone:
Main Phone:
Work Phone:
Address
(if not the same)
:
City:
State:
Zip:
Employer:
Email:
Parent/Guardian:
Middle Initial:
Last Name:
Cell Phone:
Main Phone:
Work Phone:
Address
(if not the same)
:
City:
State:
Zip:
Employer:
Email:
Complete For An Adult Patient
Your Employer:
Email:
Work Phone:
Spouse's Employer:
Email:
Work Phone:
Dental Insurance Information
Please use information from your insurance card to complete this section.
Primary
Insurance Company:
Insurance Phone:
Policy Holder's Name:
SSN:
Subscriber D.O.B.:
Employer:
Secondary
Insurance Company:
Insurance Phone:
Policy Holder's Name:
SSN:
Subscriber D.O.B.:
Employer:
Medical History
DOES THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING?
AIDS?
No
Yes
ADHD?
No
Yes
Anemia?
No
Yes
Anxiety?
No
Yes
Arthritis?
No
Yes
Artificial Heart Valve?
No
Yes
Artificial Joints?
No
Yes
Asthma?
No
Yes
Blood Disorders?
No
Yes
Blood Transfusions?
No
Yes
Bruise Easily?
No
Yes
Cerebral Palsy?
No
Yes
Congenital Heart Disease?
No
Yes
COVID-19?
No
Yes
Diabetes?
No
Yes
Emotional Problems?
No
Yes
Epilepsy (Convulsions)?
No
Yes
Frequent Headaches?
No
Yes
Glaucoma?
No
Yes
Heart Murmur/Heart Problems?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
Herpes?
No
Yes
High Blood Pressure?
No
Yes
Kidney Disorders?
No
Yes
Latex Sensitivity?
No
Yes
Liver Disease?
No
Yes
Metal Sensitivity?
No
Yes
Mitral Valve Prolapse?
No
Yes
Respiratory Problems?
No
Yes
Rheumatic Fever?
No
Yes
Snoring or Sleep Apnea?
No
Yes
Thyroid Problems?
No
Yes
Tonsil and/or Adenoid Removed?
No
Yes
Tuberculosis or Lung Disease?
No
Yes
State any reasons why the patient is currently under the care of a physician:
List any drug allergies or sensitivities:
List any medications that the patient is currently taking:
Has the patient been advised to take antibiotics prior to dental procedures?
No
Yes
List any other serious illnesses, operations or diseases not listed above:
Developmental History for Child/Teen
Girls Only
Has patient started monthly cycle?
No
Yes
If yes, age of onset:
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Dental History
Does the patient have a history of any of the following
Bleeding Gums?
No
Yes
Chipped or Injured Permanent Teeth?
No
Yes
Chronic Facial Pain?
No
Yes
Clench or Grind Teeth?
No
Yes
Difficulty Chewing or Swallowing?
No
Yes
Dizziness in Dental Chair?
No
Yes
Frequent Canker Sores?
No
Yes
Injuries to Face or Teeth?
No
Yes
Jaw Joint Pain?
No
Yes
Jaw Joints Pop or Click?
No
Yes
Jaw Locking Open or Closed?
No
Yes
Limitation in Mouth Opening?
No
Yes
Missing or Extra Permanent Teeth?
No
Yes
Mouth Breathing?
No
Yes
Muscle Tenderness in Jaw or Neck?
No
Yes
Nail Biting?
No
Yes
Periodontal Surgery?
No
Yes
Permanent Teeth Removed?
No
Yes
Speech Problems?
No
Yes
Sucks Thumb, Finger, or Lip?
No
Yes
Teeth Sensitivity - Hot/Cold?
No
Yes
Tongue Thrust?
No
Yes
List any dental problems we should know about:
Has the patient had a previous orthodontic consult or treatment?
No
Yes
If so, with who?
List the patient's chief concerns and what they would like this orthodontic treatment to accomplish?
*
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform the office of any changes in my child's medical or dental status. I authorize release of any information to insurance carriers and to other health care providers involved in my child's care. I authorize Dr. Cassaidy, Dr. Poss and the dental staff to perform any necessary dental services that are needed during diagnosis and treatment.
Digital Signature: (If minor, parent's signature.)
Date