Confidential Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
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:
*
Main Phone:
2nd/Cell Phone:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Father
Mother
Mother & Father
Please list the names of any family members we have also treated:
List any sports, hobbies, or musical instruments played:
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:
MI:
*
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:
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:
Email:
*
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Spouse or Other Parent's First Name:
MI:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
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:
Subscriber ID #:
Subscriber SSN:
Birthdate:
Group No.:
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. 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:
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:
Subscriber ID #:
Subscriber SSN:
Birthdate:
Group #:
Insurance Company:
Insurance Co. Phone No.:
Insurance Co. 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:
Dental History
Dentist Name:
Dentist Location:
I do not have a Dentist
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Medical History
*
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/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Metal Allergy
No
Yes
Other:
No
Yes
List any drug allergies or sensitivities (not listed above) that the patient may have:
All answers default to NO. Please select
YES
if the patient has had any of the conditions listed below either now or in the past.
Heart Murmur
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Angina
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Large Tonsils
No
Yes
Sinus trouble
No
Yes
Substance abuse problem (past or present)
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Prosthetic joints
No
Yes
Chronic fatigue
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Disease
No
Yes
Pneumonia
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Arteriosclerosis
No
Yes
Thyroid / Endocrine Problems
No
Yes
Stomach ulcer or hyperacidity
No
Yes
Hormone Therapy
No
Yes
Metal Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Treated for Emotional Problems
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
Persistent swollen neck glands
No
Yes
Low blood pressure
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes', please explain:
Is there anything else we should know about the patient to ensure a great experience at our office?
I have reviewed a copy of the Knox Family Smiles Notice of Privacy Practices (
click here to review
) and certify that I am over the age of 18 or the legal parent or guardian of above named patient, and that 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.
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Signature of patient if over 18 or parent/legal guardian: