Confidential Patient Information
Today's Date:
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Birthdate:
If patient is a minor, give parent’s or guardian’s name:
Dental referral:
Family/Friend referral:
Confidential Responsible Party Information
Check if Responsible Party address is the same as the Patient's.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Work Phone:
Address:
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:
Is your child apprehensive about dental visits?
Yes
No
Have there been injuries to the mouth or teeth?
Yes
No
Does your child have any speech problems?
Yes
No
Does your child breathe predominantly through the mouth?
Yes
No
Does your child experience frequent headaches?
Yes
No
Any clicking or pain in the jaw joints (TMJ)?
Yes
No
Does your child clench or grind his/her 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
Does your child still suck his/her thumb or finger?
Yes
No
Have other family members had orthodontics?
Yes
No
Who?
Has your child previously had an orthodontic evaluation or treatment?
Yes
No
Orthodontist:
Is your child concerned about the appearance of his/her 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:
Has your child ever been hospitalized?
Yes
No
Has your child ever had major surgery?
Yes
No
Is your child presently under a physician’s care for any condition?
Yes
No
Is your child taking any drugs or medications?
Yes
No
Have the tonsils or adenoids been removed?
Yes
No
Does your child have fainting or dizzy spells?
Yes
No
Has you child 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 child's hobbies and interests:
Please list names and ages of other children in your family:
Where does your child attend school?
What seems to be your child's main orthodontic problem?
How would you describe your child's 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: