Health History Form | Genesis Orthodontics

Patient's Name: Last

First

Middle

Address: Street

City

State

Zip

Nickname:

Birthdate:

Age:

Sex:

Social Security #:

Martial Status:

Single Married Widowed Divorced

Employer:

Occupation:

Home Phone:

Work Phone:

Mobile Phone:

Spouse's Name: Last

First

Middle

Spouse's birthdate:

Spouse's Employer:

Spouse's cell phone:

Phone number we should use to confirm appointments:

Text number we should use to confirm appointments:

Email address we can use for appointment reminders:

Who may we thank for referring you to our office?

Hobbies/Interests:

Name of person financially responsible for account:

Social Security #:

Birthdate:

Relationship to patient:

Address: Street

City

State

Zip

Home Phone:

Work Phone:

Mobile Phone:

Employer:

Occupation:

Correspondance should be sent to:

Patient's address Financially responsible address

Primary Dental Insurance Company & Address:

Subscriber's Name:

Subscriber's Social Security Number:

Relationship to Patient:

Subscriber's Address:

Subscriber's Date of Birth:

Subscriber's Employer:

Subscriber's ID:

Group #:

Secondary Dental Insurance Company & Address:

Subscriber's Name:

Subscriber's Social Security Number:

Relationship to Patient:

Subscriber's Address:

Subscriber's Date of Birth:

Subscriber's Employer:

Subscriber's ID:

Group #:

What is the main orthodontic problem as you see it?

Are you sensitive about the appearance of your teeth?

Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.)

What do you consider the main benefits of orthodontic treatment?

Cosmetic Functional Psychological/Emotional

Other

How do you feel about wearing braces?

Have you ever had an orthodontic consultation?

Have you ever had braces before?

If yes, When?

Has anyone else in the family received orthodontic treatment?

If yes, Who?

What would you like orthodontic treatment to accomplish?

Name of your general dentist:

Name of previous orthodontist, if applicable:

Frequency of dental checkup:

Once/year Twice/year

Date of last dental exam:

Other:

If you answered yes to any of the above, please explain:

Patient's Physician:

Approximate date of last exam:

Are you currently seeing a Physical Therapist or Chiropractor?

Yes No

If yes, name & address:

Are you currently in good physical health?

Yes No

If no, please explain:

Please list any medications you are currently taking:

List any drug allergies or sensitivities:

Right or left handed:

Other:

If you answered yes to any of the above, please explain:

Patient Information

Responsible Party Information

Insurance Information

Dental History

Medical History