CONFIDENTIAL PATIENT INFORMATION
Patient’s Name:
Age:
Birthdate:
Sex:
Prefers to be called:
Marital Status:
Referred by:
Mailing Address:
City:
State:
Zip:
Physical Address:
City:
State:
Zip:
How long at this address?
Previous Address: (if less than 3 years)
City:
State:
Zip:
Phone:
Email:
SS#:
Employer:
Occupation:
# of Years Employed:
Spouse’s Name:
Cell:
Employer:
Occupation:
# of Years Employed:
SS#:
DOB:
INSURANCE INFORMATION
Policy Holder’s Name/Relationship:
SS#:
Insurance Company:
ID #:
Group #:
DOB:
Insurance Co. Phone #:
Insurance Co. Address:
City:
State:
Zip:
Policy Holder’s Name/Relationship:
SS#:
Insurance Company:
ID #:
Group #:
DOB:
Insurance Co. Phone #:
Insurance Co. Address:
City:
State:
Zip:
EMERGENCY CONTACT INFORMATION
Name of nearest relative/friend not living with you:
Complete address
Phone
Relationship
DENTAL HISTORY
Date of Last Visit:
Have there been any injuries to the face, mouth or teeth?
Has the patient had or presently have any of the following habits?
Has the patient been informed of any missing or extra permanent teeth?
Is the patient aware of sores, lumps or irritated areas in the mouth?
Has the patient ever been treated for:
If so, who was the treating doctor?
Does the patient have any speech problems?
Is the patient frightened or anxious about orthodontic treatment?
What aspect of dental treatment is the patient most concerned with?
Reason for Consultation (Chief Concern):
Have you ever had any orthodontic treatment?
Are you satisfied with the result?
MEDICAL HISTORY
Is the patient’s general health good at this time
What is the name of the family physician?
Date of last physical
Is the patient under the care of a physician at this time?
Explain:
Is the patient taking any medication?
Name:
Is the patient allergic to any medication? (Penicillin, Sulfa, etc.)
Name:
Has the patient had tonsils and/or adenoids removed?
Age:
Has the patient ever had a serious illness or been hospitalized?
Explain:
Does the patient have any special problems not listed?
Explain:
Has the patient ever been advised by their physician to take an antibiotic prior to any dental treatments?
If yes, antibiotic name and method:
What is the patient’s approximate height?
Weight?
DOES THE PATIENT NOW, OR HAVE THEY EVER HAD ANY OF THE FOLLOWING?

Yes

No

TUBERCULOSIS
ENDOCARDITIS
HEART CONDITION
HEART PACEMAKER
HEART ANGINA
HEART ATTACK (CORONARY)
MITRAL VALVE PROLAPSE
CONGENITAL HEART DISEASE
ARTIFICAL HEART VALVE
HEART SURGERY; Date
HEART MURMUR
RHEUMATIC FEVER
PROSTHETIC (ARTIFICAL) JOINT
X-Ray/Radiation (cancer) therapy
AIDS OR H.I.V. POSITIVE
DIABETES

Yes

No

RESPIRATORY LUNG DISEASE
HIGH BLOOD PRESSURE
LOW BLOOD PRESSURE
HEPATITIS (type?)
VENEREAL DISEASE
HERPES (ORAL-COLD SORES)
BLOOD DISORDERS/BLEEDING PROBLEMS
INFLAMMATORY RHEUMATISM
ARTHRITIS
ULCERS
STROKE
ANEMIA
ASTHMA
EPILEPSY
GLAUCOMA
CANCER

Yes

No

ADD
KIDNEY TROUBLE
LIVER DISEASE
PSYCHIATRIC TREATMENT
DRUG ADDICTION
HEADACHES
EARACHES
JAW CLICKING
ALLERGIES
ALLERGIES TO METAL
JAW PAIN
TONSILLITIS
EMOTIONAL PROBLEMS
FAINTING SPELLS
Other
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION NOT DISCLOSED. I understand that when appropriate a credit report may be obtained.

Patient Signature

Date

ACKNOWLEDGEMENT OF HIPPA PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*

I,

Print Patient Name

understand the Notice of HIPPA/Privacy Practices

(Copy of HIPPA form available on request)

Patient Signature

Date