PATIENT INFORMATION

Please COMPLETE ALL information. Thank you.
Patient Age:
Patient First Name:
Middle Initial:
Patient Last Name:
Address:
City:
State:
Zip:
Home Phone:
Birth Date:
Social Security #:
If patient is a minor, give parent or guardian's name:
Office location preference:
How did you hear about our office?

RESPONSIBLE PARTY INFORMATION

Last Name:
First Name:
Middle Initial:
Marital Status:
Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Own or Rent?
Previous address (if less than 3 years)
Home phone:
Work phone:
Cell phone:
Social Security #:
Birth Date:
Relationship to Patient:
Employer:
Occupation:
# of years employed:
Responsible Party e-mail address:
Spouse's Last Name:
Spouse's First Name:
Spouse's Middle Name:
Relationship to Patient:
Marital Status:
Spouse's Social Security #:
Spouse's Mailing Address:
Spouse's Employer:
Occupation:
# years employed:
Spouse's Birth Date:
Spouse's Work Phone:
Spouse's Cell Phone:
Spouse's e-mail address:

EMERGENCY INFORMATION

Name of Nearest Relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

INSURANCE INFORMATION

Insured's Name:
DOB:
Insured's ID#:
Insured's Address:
Ins. Co. Phone:
Insurance Company:
Group #:
Insured's Employer:
Do you have dual coverage?
If yes, please continue:
Insured's Name:
DOB:
Insured's ID#:
Insured's Address:
Ins. Co. Phone:
Insurance Company:
Group #:
Insured's Employer:

MEDICAL HISTORY

**Your answers are for office records only and are kept confidential. A thorough medical history is essential to a complete orthodontic evaluation.**
Have you ever had any of the following?
Birth defects or hereditary problems
Bone fractures or major injuries
Any injury to the head, neck, or face
Arthritis or joint problems
Endocrine or thyroid problems
Diabetes or low blood sugar
Kidney problems
Cancer, tumor
Radiation or chemotherapy
Stomach ulcer or acid reflux
Immune system problems
Osteoporosis
Sexually transmitted disease
AIDS or HIV positive
Hepatitis, jaundice, other liver problems
Polio, Mono, TB, or Pneumonia
Seizures, fainting spells
Depression
Vision or hearing problems
History of Anorexia or Bulimia
High or low blood pressure
Bruise easily, Anemia
Chest pain, shortness of breath, tire easily
Swollen ankles
Heart defect, murmur, heart attack
Sickle Cell Disease
Mitral Valve Prolapse, heart disease
Stroke
Skin disorder (other than acne)
Frequent headaches or migraines
Asthma, sinus problems, hay fever
Speech problem and/or therapy
Tonsil or adenoid condition
Latex or Nickel sensitivity
Cold sores/fever blisters
Nervous/Anxious
Rheumatic Fever
Hemophilia, Excessive bleeding
Are you currently undergoing any medical treatment?
Take Bisphosphonates?
If YES, for what?
Who is your physician?
Are you currently taking any medications?
If YES, please list all medications.
Are you allergic to any medications?
If YES, please list.
Do you have any allergies (for example: cats, milk, seasonal)?
If YES, please list.
Are you pre-medicated for major dental work and cleanings?
If YES, please list the medication.
Do you chew or smoke tobacco?
If you are a woman, are you pregnant?
Are there any other health problems not listed?
If YES, please describe.

DENTAL HISTORY

Dentist Name:
Dentist Location:
Any dental pains or problems needing attention?
If YES, please describe.
Have you ever bumped, chipped, or fractured any teeth?
Do you snore?
Is it difficult to breath through your nose?
Do you breath with your mouth constantly open?
Do you have any of the following habits?

TMJ (JAW JOINT) HISTORY

Do you or have you ever had a TMJ problem?
If YES, have you ever been treated?
By Whom?
When?
Please describe your problem and/or concern.
I understand that I will be responsible for all lab fees incurred in the fabrication of a splint or orthodontic appliance in the event that I choose not to continue treatment. I understand that it is policy of Puntillo & Crane Orthodontics that the parent who requests treatment for a minor child shall be responsible for all services rendered.
Initials:
To enable us to better set the terms of credit for you or your child's care, today we will obtain the appropriate credit bureau reports.
Signature:
Date:
I represent that all the statements and answers contained herein, are to the best of my knowledge and belief, complete, true and correctly recorded and it is agreed that Puntillo and Crane Orthodontics P.C., and staff shall not be presumed to have knowledge of any information not so recorded.
By typing my name, I am agreeing this is my Electronic Signature.
Patient's Signature (Parent if patient is a minor):
Date: