PATIENT
Date
Patient’s last name
First name
Middle initial
Title:
Mr.
Mrs.
Ms.
Dr.
Other
I prefer to be called
Birthdate
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
01
02
03
04
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2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Sex:
Male
Female
Social Security #
Marital Status:
Single
Married
Separated
Divorced
Widowed
Home address
City, State, Zip code
Home phone
Cell phone
Work phone
Email address(es)
EMERGENCY INFORMATION
Spouse or closest relative’s name(s)
Title:
Mr.
Mrs.
Ms.
Dr.
Other
Relationship to patient:
Address (if different than patient address)
Home phone
Cell phone
Work phone
DENTIST
Patient’s Dentist
City, State
Last seen
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
1916
1917
1918
1919
1920
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1920
1921
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1953
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1961
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1977
1978
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1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Reason
Next appointment
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
2018
2019
2020
2021
2022
Other dentists/dental specialists now being seen: Name
City, State
Reason
GENERAL INFORMATION
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you had any previous orthodontic treatment? Please describe.
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address
City, State, Zip
How long have you been at this address?
Home phone
Cell phone
Email address(es)
Social Security #
Occupation
Employer
Number of years employed
DENTAL INSURANCE
Primary policy holder’s full name
Birthdate
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1916
1917
1918
1919
1920
1921
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
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1961
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1968
1969
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1972
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1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
Secondary policy holder’s full name
Birthdate
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1916
1917
1918
1919
1920
1921
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
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1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
MEDICAL INSURANCE
Policy holder’s full name
Insurance company
PHYSICIAN
Patient’s physician
City, State
Last seen
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
1916
1917
1918
1919
1920
1921
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Reason
Next appointment
Select Month
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Nov
Dec
2018
2019
2020
2021
2022
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
Name
City, State
Reason
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don’t know/understand (dk/u).
MEDICAL HISTORY
Now or in the past, have you had:
Yes
No
DK/U
Yes
No
DK/U
Birth defects or hereditary problems?
Yes
No
DK/U
Bone fractures or major injuries?
Yes
No
DK/U
Any injuries to face, head, neck?
Yes
No
DK/U
Arthritis or joint problems?
Yes
No
DK/U
Endocrine or thyroid problems?
Yes
No
DK/U
Diabetes or low sugar?
Yes
No
DK/U
Kidney problems?
Yes
No
DK/U
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
DK/U
Stomach ulcer, hyperacidity, acid reflux?
Yes
No
DK/U
Immune system problems?
Yes
No
DK/U
History of osteoporosis?
Yes
No
DK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
DK/U
AIDS or HIV positive?
Yes
No
DK/U
Hepatitis, jaundice, or other liver problems?
Yes
No
DK/U
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
DK/U
Seizures, fainting spells, neurologic problems?
Yes
No
DK/U
Yes
No
DK/U
Mental health problems or depression?
Yes
No
DK/U
Vision, hearing, or speech problems?
Yes
No
DK/U
History of eating disorder (anorexia, bulimia)?
Yes
No
DK/U
High or low blood pressure?
Yes
No
DK/U
Excessive bleeding or bruising, anemia?
Yes
No
DK/U
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
DK/U
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
DK/U
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
DK/U
Skin disorder (other than common acne)?
Yes
No
DK/U
Do you eat a well-balanced diet?
Yes
No
DK/U
Frequent headaches or migraines?
Yes
No
DK/U
Frequent ear infections, colds, throat infections?
Yes
No
DK/U
Asthma, sinus problems, hayfever?
Yes
No
DK/U
Tonsil or adenoid condition?
Yes
No
DK/U
Do you frequently breathe through your mouth?
Have you had allergies or reactions to any of the following?
Yes
No
DK/U
Yes
No
DK/U
Local anesthetics (novocaine, lLatex (gloves, balloons)
Yes
No
DK/U
Latex (gloves, balloons)
Yes
No
DK/U
Aspirin
Yes
No
DK/U
Metals (jewelry, clothing snaps)
Yes
No
DK/U
Penicillin
Yes
No
DK/U
Other antibiotics
Yes
No
DK/U
Yes
No
DK/U
Ibuprofen (Motrin, Advil)
Yes
No
DK/U
Acrylics
Yes
No
DK/U
Plant pollens
Yes
No
DK/U
Animals
Yes
No
DK/U
Foods
Yes
No
DK/U
Other substances
DENTAL HISTORY
Now or in the past, have you had:
Yes
No
DK/U
Yes
No
DK/U
Permanent or extra (supernumerary) teeth removed?
Yes
No
DK/U
Supernumerary (extra) or congenitally missing teeth?
Yes
No
DK/U
Chipped or injured primary or permanent teeth?
Yes
No
DK/U
Any sensitive or sore teeth?
Yes
No
DK/U
Bleeding gums, bad taste or mouth odor?
Yes
No
DK/U
Jaw fractures, cysts, infections?
Yes
No
DK/U
Any teeth treated with root canals or pulpotomies?
Yes
No
DK/U
“Gum boils,” frequent canker sores or cold sores?
Yes
No
DK/U
History of speech problems or speech therapy?
Yes
No
DK/U
Difficulty breathing through nose?
Yes
No
DK/U
Food impaction between the teeth?
Yes
No
DK/U
Mouth breathing habit or snoring at night?
Yes
No
DK/U
Yes
No
DK/U
Frequent oral habits (sucking finger, chewing pen, etc)?
Yes
No
DK/U
Teeth causing irritation to lip, cheek or gums?
Yes
No
DK/U
Abnormal swallowing (tongue thrust)?
Yes
No
DK/U
Tooth grinding or clenching?
Yes
No
DK/U
Clicking, locking in jaw joints?
Yes
No
DK/U
Soreness in jaw muscles or face muscles?
Yes
No
DK/U
Ringing in ears, difficulty in chewing or opening jaw?
Yes
No
DK/U
Have you ever been treated for “TMJ” or “TMD” problems?
Yes
No
DK/U
Any broken or missing fillings?
Yes
No
DK/U
Any serious trouble associated with previous dental treatment?
Yes
No
DK/U
Have you ever been diagnosed with gum disease or pyorrhea?
Yes
No
DK/U
Have you ever had an orthodontic consultation or treatment?
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you take antibiotic pre-medication before any dental procedures?
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?
Yes
No
Are you trying to become pregnant?
Yes
No
FAMILY MEDICAL HISTORY
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health. I authorize the orthodontic staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature
Clear
Date:
AUTHORIZATION
This office reserves the right to verify the credit status of potential patients and/or parents prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the orthodontist to release all information necessary to secure the payment of benefits. I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submissions, whether manual or electronic.
I authorize any photographs, x-rays, or study models to be used for displays at scientific meetings, presentations, and publications of scientific nature or for study group purposes (to further the art and science of orthodontics) or for the use in our office and for advertising/marketing purposes.
Signature
Clear
Date: