Confidential Patient Information

Today's Date:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Birthdate:
Social Security:

Whom may we thank for referring you to our office?

Confidential Responsible Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
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:
Employer:
Occupation:
No. Years Employed:

2nd Responsible Party First Name:
Middle Initial:
Last Name:
Relationship to Patient:
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?
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?
Have there been injuries to the mouth or teeth?
Do you have any speech problems?
Do you breathe predominantly through the mouth?
Do you experience frequent headaches?
Any clicking or pain in the jaw joints (TMJ)?
Do you clench or grind your teeth?
Do you know of any extra permanent teeth?
Do you know of any missing permanent teeth?
Is there bleeding during brushing or flossing?
Have you been told you have gum disease?
Have other family members had orthodontics?
Who?
Have you previously had an orthodontic evaluation or treatment?
Orthodontist:
Are you concerned about the appearance of your teeth?
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?
Have you ever had major surgery?
Are you presently under a physician’s care for any condition?
Are you taking any drugs or medications?
Have the tonsils or adenoids been removed?
Do you have fainting or dizzy spells?
Have you been diagnosed or treated for any of the following?
Heart problems
Kidney problems
Allergies
Liver problems
Rhuematic fever
Hepatitis
Lung problems
Exposure to AIDS
Asthma
Diabetes
Bone problems
Prolonged bleeding
Epilepsy
Psychological problems
Arthritis
Anemia
Tuberculosis
Sleep Apnea
Snoring
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: