Confidential Patient Information
Date
Name (& Preferred name)
Sex
Male
Female
Age
Patient’s Address
City:
State
Zip
Cell phone (if applicable)
Cell Carrier
Birthdate
Patient’s School District
Grade
Interest/Hobbies
Has Dr. Hunt treated others in your family?
Yes
No
Name of that family member
Parent’s E-mail address
(to receive appointment reminders)
Confidential Responsible Party Information
Name
Marital Status
Address
City:
State
Zip
How long at this address?
Own
Rent
Cell Phone
Work Phone
Employer
Occupation
No. Years Employed
SSN#
Birthdate
Relationship to Patient
Spouse’s Name
Relationship to Patient
Employer
Occupation
No. Years Employed
SSN#
Birthdate
Cell phone
Dental Insurance Information
Policy Holder’s Name
ID# or SSN#
Birthdate
Relationship to Patient
Cell Phone
Address
(if different from patient)
Insurance Company.
Group No.
Insurance Co. Address
Ins Phone #
Policy Holder’s Employer
Do you have dual coverage?
No
Yes
If Yes:
Policy Holder’s Name
ID# or SSN#
Birthdate
Relationship to Patient
Cell Phone
Address
(if different from patient)
Insurance Company.
Group No.
Insurance Co. Address
Ins Phone #
Policy Holder’s Employer
I hereby assign insurance benefits to Dr. J. Todd Hunt
Signature (Parent or Guardian, if minor)
Date Signed:
Medical History
What is the patient's present health?
Good
Fair
Poor
Name of Family Physician
Circle any of the following that you have had (past or present):
Heart disease
Liver problems or Hepatitis
HIV+ or AIDS
Artificial heart valve
Kidney problems
Cancer or tumors
Heart murmur
Diabetes
Cleft lip/palate
Rheumatic fever
Arthritis
Tonsils or Adenoids removed
Asthma
Bleeding problems
Speech or hearing problems
Epilepsy/Seizures
Others
Please list any:
Medications the patient is presently taking
Medications the patient is allergic to
Surgeries or emergency treatment you have undergone:
Do you smoke/vape?
Yes
No
Females:
Has menstruation begun?
Yes
No
(This tell us the status of skeletal maturation, including growth of the jaws)
Is the patient pregnant now?
Yes
No
(For X-ray purposes)
Dental History
Family Dentist
Whom may we thank for recommending our office?
Has the patient ever had any injuries to the jaws, mouth, or teeth?
Yes
No
If yes, explain
Circle any of the following that you have had (past or present):
Toothaches/sensitive teeth
Grinds or clenches teeth
Cavities
Jaw joint or muscle pain
Bleeding gums
Frequent headaches
Thumbsucking
Mouthbreathing or difficulty breathing through nose
What is your main reason for seeking this appointment?