Health History Form | Advanced-Orthodontics-of-Wisconsin

Patient Biographical Information

*First Name:

*Last Name:

*Middle Initial:

*Marital Status:

*Gender: Male Female

*Birth Date:

*Address:

*Patient Phone:

*City:

Work Phone:

*State:

*Zip Code:

Patient Cell:

Reminder: Y N

Email:

Reminder: Y N

How did you hear about us?:

*Dentist:

We confirm appointments using email and text messaging.

Financial Party or Account Access Information:

IF THE PATIENT IS A MINOR, PLEASE PROVIDE RESPONSIBLE PARTY INFORMATION:

Responsible Party

Name/Relationship:

Account Access (circle one): FULL NONE

Address:

Phone:

City:

Work Phone:

State:

Zip code:

Cell:

Email:

Name/Relationship:

Account Access (circle one): FULL NONE

Address:

Phone:

City:

Work Phone:

State:

Zip code:

Cell:

Reminder: Y N

Email:

Reminder: Y N

Patient Heath History:Your careful and complete answers to the following questions will be helpful in the preparation of an orthodontic program for you or your child. Only by knowing the many factors which can influence a problem is it possible for the orthodontist to recommend the most suitable and beneficial therapy.
REMINDER: Women who are pregnant, or think that they may be pregnant, must notify the assistant to avoid x-rays.

DR G.

Current medications being taken:

Any History of:

:Arthritis

:Bone/Joint disease

:Auto Immune Diseases

:Epilepsy/Convulsions

:Blood Disease

:Diabetes

:Heart disease, Rheumatic fever

:TMJ/Jaw Abnormalities

:HIV/AIDS

:Kidney trouble

:Asthma, Allergies, Hay fever

:High or low blood pressure

: X-Ray exposure, extensive

:Cancer

:Liver problems

:Gingivitis/Gum Disease

:Hepatitis

:Injury, tooth extraction, or missing teeth

:Have you ever taken Bio phosphates? i.e. Fosamax, Boniva, etc…

:Prolonged bleeding following extractions

If YES to any of the above, Please comment:

:Food Allergies

:Thumb/Finger Habit

:Good General Health

:Major Operations

:Injury to Face/Mouth/Teeth

:Difficulty Chewing/Swallowing

:Tonsils/Adenoids Removed

: Are you Pregnant?

:Puberty reached?

:Previous orthodontic treatment

:Difficulty breathing through nose

:Boys – Voice Changed, Girls – Menstruation started?

If YES to any of the above, Please comment:

Do you have Dental/Orthodontic Insurance?

If Yes, please complete the following:

Policy Holder:

Policy Holders DOB:

Relationship to Patient:

Insurance Company:

Subscriber #:

Group #:

Ins. Co. Phone #:

Ins. Co. Address:

Employer:

If you have dual coverage, please provide information on second insurance plan:

Policy Holder:

Policy Holders DOB:

Relationship to Patient:

Insurance Company:

Subscriber #:

Group #:

Ins. Co. Phone #:

Ins. Co. Address:

Employer:

By providing your insurance information, you agree that we may share any information requested by your insurance provider for the purposes of your claim. You also authorize us to invoice your insurance and be paid directly by them.

I agree that the information provided on this form is accurate and completed fully to the best of my ability:

Relationship to Patient:

Today’s Date:

Person Completing this form (Printed Name):

Signature: