Confidential Patient Information
Today's Date:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Birthdate:
Social Security #:
Dental referral:
Family/Friend referral:
Confidential Responsible 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
Residence:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Work Phone:
Previous Address (if less than 3 yrs.):
City:
State:
Zip:
Email:
Cell Phone:
Social Security #:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
No. Years Employed:
2nd Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
No. Years Employed:
Social Security #:
Birthdate:
Work Phone:
Email:
Cell Phone:
Orthodontic Insurance Information
Insured's Name:
Insured’s Soc. Sec. #:
Insurance Company:
Group No.:
I.D. No:
Insurance Co. Address:
Do you have dual coverage?
Yes
No
If yes:
Insured's Name:
Insured’s Soc. Sec. #:
Insurance Company:
Group No.:
I.D. No:
Insurance Co. Address:
Insured's Employer:
Emergency Information
Name of nearest relative/friend not living with you:
Relationship:
Complete Address:
Phone:
Cell Phone:
Dental History
Dentist's Name:
Date of last Visit:
Are you apprehensive about dental visits?
Yes
No
Have there been injuries to the mouth or teeth?
Yes
No
Do you have any speech problems?
Yes
No
Do you breathe predominantly through the mouth?
Yes
No
Do you experience frequent headaches?
Yes
No
Any clicking or pain in the jaw joints (TMJ)?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you know of any extra permanent teeth?
Yes
No
Do you know of any missing permanent teeth?
Yes
No
Is there bleeding during brushing or flossing?
Yes
No
Have you been told you have gum disease?
Yes
No
Have other family members had orthodontics?
Yes
No
Who?
Have you previously had an orthodontic evaluation or treatment?
Yes
No
Orthodontist:
Are you concerned about the appearance of your teeth?
Yes
No
Are there any other dental/orthodontic problems Dr. Hulme should be aware of:
Medical History
Physician's Name:
Date of last visit:
Have you ever been hospitalized?
Yes
No
Have you ever had major surgery?
Yes
No
Are you presently under a physician’s care for any condition?
Yes
No
Are you taking any drugs or medications?
Yes
No
Have the tonsils or adenoids been removed?
Yes
No
Do you have fainting or dizzy spells?
Yes
No
Have you been diagnosed or treated for any of the following:
Heart problems
Yes
No
Kidney problems
Yes
No
Allergies
Yes
No
Liver problems
Yes
No
Rhuematic fever
Yes
No
Hepatitis
Yes
No
Lung problems
Yes
No
Exposure to AIDS
Yes
No
Asthma
Yes
No
Diabetes
Yes
No
Bone problems
Yes
No
Prolonged bleeding
Yes
No
Epilepsy
Yes
No
Psychological problems
Yes
No
Arthritis
Yes
No
Anemia
Yes
No
Tuberculosis
Yes
No
Sleep Apnea
Yes
No
Snoring
Yes
No
Please describe any pertinent medical history below:
Other Information
Please give us an idea of your hobbies and interests:
Please list names and ages of any children of yours:
What seems to be your main orthodontic problem?
How would you describe your attitude toward possible orthodontic treatment?
I represent that the information on this form is accurate and correct. If there is a change in the information I have provided, I will promptly notify the office. I understand that where appropriate, credit bureau reports may be obtained.
Signature:
Date: