Page 1 of 4
Date
Confidential Patient Information
Patient's Name
last
First
Middle
M
F
Address
Street
City
State
Zip
Home Phone
Birthdate
Social Security#
If patient is a minor, give parent's or guardian's name
How did you hear about our office?
Name of person referring
Confidential Responsible Party/Adult Patient Information
Name
Last
First
Middle
Marital Status
Residence
Street
City
State
Zip
Own
Rent
Mailing Address
Street
City
State
Zip
Email
How long at this address
Previous Address
(if less than 3 years)
Street
City
State
Zip
Cell Phone
Home Phone
Social Security#
Birthdate
Relationship to Patient
Employer
Occupation
No.Years Employed
Spouse's Name
Last
First
Middle
Relationship to Patient
Cell Phone
Home Phone
Social Security#
Birthdate
Email
Employer
Occupation
No.Years Employed
Emergency Information
Emergency Contact's Name
Phone
Relationship
I understand that where appropriate, credit bureau reports will be obtained.
Patient/ Parent/ Guardian Signature
Date
Updates (date & initial)
Page 2 of 4
Do you have Dental Insurance?
Yes
No
If yes please provide information.
Insurance Information
Policy Holder's Name
Soc. Sec.#
Policy Holder's Employed by
Insurance Company
Policy Holder's Birthdate
Insurance Co. Phone
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with insurance claim.
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Murray & Olson Orthodontics
Subscriber Signature of 1st Insurance
Date
Do you have dual coverage?
Yes
No
If yes fill out section B.
Section B Insurance Information
Policy Holder's Name
Soc. Sec.#
Policy Holder's Employed by
Insurance Company
Policy Holder's Birthdate
Insurance Co. Phone
I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with insurance claim. activities in connection with insurance claim.
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Murray & Olson Orthodontics
Subscriber Signature of 2nd Insurance
Date
Patient History
Page 3 of 4
Patient's Name
What is your chief concern for us at this visit?
Medical History
Do you have a personal physician?
Yes
No
Physician's Name:
Phone#:
Date of last visit:
Your current physical health is:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Please explain:
Do you smoke or use tobacco in any other form?
Yes
No
Have you had any metal rods, pins or implants?
Yes
No
Are you taking any prescription/over-the-counter drugs?
Yes
No
Please list each one:
Have you ever taken Phen-Fen?
Also known as Redux or Pondimin
Yes
No
If so, when?
For Women:
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
Week#:
Are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding/Hemophilia
AlDS
Alcohol/DrugAbuse
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surger
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Asprin
Erythromycin
Penicillin
Codeine
Jewelry/Metals
Tetracycline
Dental Anesthetics
Latex
Other
Please list any other drugs/materials that you are allergic to:
Page 4 of 4
Dental History
Name of patient's dentist:
Date of last dental exam:
Has another family member received orthodontic treatment in our office?
Yes
No
Who?
Have you ever had or been evaluated for orthodontic treatment?
(Mark all that apply)
Chipped or injured permanent teeth
Teeth sensitive to hot or cold
Jaw fractures, cyst, mouth infections
Previous root canal therapy
Bleeding gums or bad taste/mouth odor
Other periodontal (gum) problems
Problems with food trapped between teeth
Frequent canker sores or cold sores
Mouth breathing habit or snoring troubles
Abnormal swallowing (tongue thrust)
Has there been a negative dental experience?
Would you consider the patient's diet high in sweets/sugars?
History of missing or extra teeth
Have any permanent teeth been removed?
Have wisdom teeth been removed?
Previous orthodontic treatment or retainer
Previous periodontal (gum) treatment
Numerous fillings
Damaged restorations or fillings
Thumb or finger habit as a child
Loose or shifting teeth
Is all dental work completed at this time?
Patient's deciduous ("baby") teeth came in:
EARLY
AVERAGE
LATE
Patient's deciduous ("baby") teeth were lost:
EARLY
AVERAGE
LATE
Patient's mouth most resembles:
MOTHER
FATHER
BOTH
NEITHER
TMJ (Jaw Joint) History
(Mark all that apply)
Has the patient had a TMJ screening?
Does the patient have a history of jaw joint problems?
Has the patient been treated for "TMJ"?
Does his/her bite feel uncomfortable or unusual?
Does the patient grind his/her teeth?
Does the patient clench his/her teeth?
Has the patient's jaw ever locked?
Does the patient have pain in his/her jaw joint?
Does the patient experience soreness in the muscles of his/her face or around ears?
Does the patient notice clicking or popping in his/her jaw joint?
Does the patient have difficulty chewing or opening his/her mouth?
**I certify that I read and understand the above. I acknowledge that I have completed this form to my best knowledge, and that my questions have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of my child's form. If there are any changes later to this history record or medical or dental status, I will inform the practice.
Signature of Patient/Parent/Guardian
Date
Scott B. Murray, D.M.D. / Jeffrey C. Olson, D.D.S
Date
Update Signature
Date
Update Signature
Date
Update Signature
Date
Update Signature
Date