Confidential Patient Information
*
First Name:
Middle Initial::
*
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Parents
Mother
Father
Other
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Married
Single
Divorced
Widowed
How long at this address?
Own or Rent?
Main Phone:
2nd/Cell Phone:
Email:
Birthdate:
Relationship to Patient:
Parent
Grandparent
Guardian
Spouse
Self
Address:
City:
State:
Zip:
Previous Address (less than 3 years)
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Spouse or Other Parent's First Name
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:
Length of Employment:
Work Phone #:
Relationship to Patient:
Parent
Grandparent
Guardian
Spouse
Dental Insurance Information
Primary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Parent
Grandparent
Guardian
Self
Spouse
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Parent
Grandparent
Guardian
Self
Spouse
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Parent
Grandparent
Guardian
Dental History
Dentist Name:
Check-up Frequency:
6 months
Yearly
Every other year
other
Last Dental Visit:
Has the patient had an orthodontic consultation or treatment?
No
Yes
If so, when?
By whom?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
No
Yes
Speech problems/therapy?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Clench or Grind Teeth?
No
Yes
Pain, tenderness or noise in either jaw joint?
No
Yes
Frequent headaches/earaches?
No
Yes
Neck/shoulder pain?
No
Yes
Does jaw joint ever get "stuck", "locked", or "go out"?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Does the Patient need to premedicate prior to dental visit?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
Patient Health:
Good
Fair
Poor
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
No
Yes
Rheumatic Fever
No
Yes
Tuberculosis
No
Yes
Pneumonia
No
Yes
Liver Disease
No
Yes
Kidney Disease/Jaundice/Hepatitis
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Damaged/Artificial Heart Valve
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Sexually Transmitted Disease
No
Yes
Tonsils/Adenoids Removed
No
Yes
Chew or Smoke Tobacco
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Growth Problems
No
Yes
Thyroid / Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Metal/Latex Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Bone Fractures/Trauma to face/jaw
No
Yes
Diabetes
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Handicaps/Disabilities
No
Yes
Asthma/Sinus Problems
No
Yes
Arthritis/Joint Problems/Prosthetic Joints
No
Yes
Treated for Emotional Problems
No
Yes
Ever been Hospitalized
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
Please Provide any additional information that you feel would be helpful in the diagnosis and treatment of your condition.
Patient or Parent/Guardian Initials