Goodman Orthodontics

Patient Information

Name: Last

First

M.Ini

I prefer to be called:

Male Female

Birthdate:

Age:

SS#

Single Married Widowed Divorced Separated

Address:

How long at this address

yrs

months

Own Rent

Other

Previous address (if less than 3 years)

Hm#:

Wk#

E-mail:

Preferred method of contact:

Text Email Phone

Perferred contact time:

Morning Afternoon Evening

Employer/school name:

Employer/School Address:

Occupation:

How long there?

Whom may we Thank for referring you?

Other family members seen by us?

In the event of an emergency, who would you like us to contact?

His/Her Name:

Relation:

Wk#:

Hm#:

Responsible Party (Account Holder)

(please fill out if you are not the patient)

Single Married Widowed Divorced Separated

Relation:

Occupation:

How long employed at current job?

Wk#:

Ext.

SS#:

Birthdate:

Age:

Billing Address:

How long at this address

yrs

months

Own Rent

Other

Previous address (if less than 3 years)

Email:

Primary Insurance Policy Holder

Orthodontic/Dental Coverage?

Yes No

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone#:

Group # (Plan, Local, or Policy #):

Insured's Name:

Relationship to Patient:

Insured's Birthdate:

Insured's SS#:

Insured's Employer:

PATIENT MEDICAL HISTORY

Do you have a primary care physician?

Yes No

Physician's Name:

Phone #:

Patient’s Current physical health is:

Good Fair Poor

Are you currently under the care of a specialist?

Yes No

Please explain:

Are you taking any prescription/over the counter drugs?

Yes No

Please list all with dosages:

For women:

Are you taking birth control pills?

Yes No

Are you pregnant?

Yes No

Week #:

Are you nursing?

Yes No

Are you allergic to any of the following?

Y N

Aspirin

Y N

Dental Anesthetics

Y N

Penicillin

Y N

Any Metals/Plastics

Y N

Codeine

Y N

Latex

Y N

Tetracycline

Y N

Erthromycin

Y N

Sulfa drugs

Y N

Other

If other please list:

619.749.4033 | Brock Goodman, DDS

GoodmanOrtho.com | info@SanteeOrthodontics.com

8840 N. Magnolia Ave #260 | Santee, California 92071

MEDICAL HISTORY continued

Do you currently have or have you had any of the following conditions or medical issues?

Y N

Anemia

Y N

Heart Surgery

Y N

Pacemaker

Y N

Artificial Bones/Joints

Y N

Hemophilia/Abnormal Bleeding

Y N

High or Low Blood Pressure

Y N

Artificial Valves

Y N

Arthritis

Y N

Hepatitis

Y N

HIV +/AIDS

Y N

Asthma

Y N

Drug/Alcohol Abuse

Y N

Blood Transfusion

Y N

STDs

Y N

Rheumatic/Scarlet Fever

Y N

Hospitalized for Any Reason longer than 2 days

Y N

Tuberculosis

Y N

Shingles

Y N

Congenital Heart Defect

Y N

Kidney Problems

Y N

Diabetes

Y N

Mitral Valve Prolapse

Y N

Emphysema/COPD

Y N

Psychiatric Problems

Y N

Migraines

Y N

Glaucoma

Y N

Severe/Frequent Headaches

Y N

Sinus Problems

Y N

Epilepsy/Seizure

Y N

Chemotherapy

Y N

Fever Blisters/Herpes

Y N

Stroke

Y N

Heart Murmur

Y N

Tuberculosis

Y N

Heart Attack

Y N

Ulcers/Colitis

Y N

Cancer

Y N

Other

If you selected Yes for any of the above please explain:

DENTAL HISTORY

General Dentist:

Last Visit Date:

Any unfinished treatment?

Have you ever had a serious/difficult problem associated with any previous dental work?

Y N

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ / TMD)?

Y N

Your current dental health is:

Good Fair Poor

Do you like your smile?

Y N

Do your gums bleed?

Y N

Have you ever had an injury to your:

Mouth Teeth Chin

If you selected one please explain:

Do you have any speech problems?

Do you generally breathe through your mouth?

Y N

Awake?

Y N

Asleep?

Do you have any missing or extra permanent teeth?

Y N

Have you ever been evaluated for orthodontic treatment?

Y N

If yes, Doctor’s name and how long ago:

What are the main concerns that you would like orthodontics to accomplish?

Thank you for filling out this form completely. We are required by law to maintain the privacy of and provide individuals with, this information of our legal duties and privacy practices with respect to protected health information. If you have any objections to this, please ask to speak with HIPPA compliance officer in person or by phone at our main number. The signature below is an acknowledgement that we have provided this notice of our Privacy Practices. Goodman Orthodontics reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. I acknowledge the information I provided is acurate to the best of my knowledge. It is my responsibility to inform the office of any medical or insurance changes. I verbally retrieved the medical / dental information above with the patient named herein.

Patient/Guardian Signature

Date:

Dr. Goodman Initials:

Date:

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDA and the ADA.