Smile Design Ortho Health History Form

New Patient Form

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we will be asking the following questions to reduce the chances of transmission:

Have you, your child, or others accompanying you to today's appointment or other recent acquaintances tested positive for or been diagnosed as having COVID-19 or any other communicable disease?

Yes No

If yes, when? Date

Do you Your child or other accompanying you to today's appointment or other recent acquaintances have:

A Fever (defined as above 99.6 degrees)

Yes No

A Cough?

Yes No

Shortness of Breath and/or Trouble Breathing?

Yes No

Persistent pain, pressure, or Tightness in the Chest?

Yes No

I understand that if the answer to any of these questions is yes, I will be asked to reschedule today's othodontic appointment.

Patient /Guardian Signature:

Date

Submit your health history form online to your orthodontist today.

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form and click "submit". Your information will be sent to our office with secure encryption. We will have your information when you arrive for your first appointment.

Patient Information

Date

First Name:

Middle Name:

Last Name:

Address:

City:

State:

Zip code:

Home Phone #:

Birthdate:

Marital Status:

Sex:

Male Female

If patient is a minor, parent's / guardian's name:

Name and Ages of Siblings:

Email:

Whom may we thank for referring you to our office?

Sports/Hobbies/Musical Instruments:

School/Occupation:

Current Grade:

Nickname:

Person Responsible For Account

Same as Above?:

Yes No

Have you been at this address longer than 3 years?:

Yes No

Work Phone:

Cell Phone:

Social Security #:

Relationship to Patient:

Employer:

Occupation:

No. of years employed:

Spouse's Name:

Sex:

Male Female

Relationship to Patient:

Spouse's Employer:

Occupation:

No. of years employed:

Social Security #:

Birthdate:

Work Phone:

Cell Phone:

Dental Insurance Information

Insured's Name:

Insured's Birthdate:

Social Security #:

Insurance Company:

Group No.:

Phone:

Insurance Co. Address:

Insured's Employer:

Subscriber/Employee ID #:

Do you have dual coverage?

Yes No

Emergency Information

Name of nearest relative not living with you:

Relationship:

Cell or Phone:

Complete Address:

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

Please describe concerns:

Has the patient ever been evaluated for or had orthodontic treatment before?

Yes No

Have there been any injuries to the face, mouth, teeth or chin?

Yes No

How does the patient feel about wearing orthodontic appliances?

Have adenoids or tonsils been removed?

Yes No

Has the patient been informed of any missing or extra permanent teeth?

Yes No

Has the patient ever had any pain/tenderness in his/her jaw joint (TMJ/TMD)?

Yes No

Does the patient brush his/her teeth daily?

Yes No

Floss his/her teeth daily?

Yes No

Patient's Dentist:

Phone:

Date of Last Visit:

Patient's Physician:

Phone:

Is the patient currently under the care of a physician?

Yes No

Has puberty begun?

Yes No

If yes, when?

Please describe the patient's current physical health:

Good Fair Poor

Do you take or have you taken an osteoporosis medication?

Yes No

Please list all drugs that the patient is currently taking:

Please list all allergies (drugs, foods, other):

Has the patient ever had any of the following medical problems?

Abnormal Bleeding

Yes No

ADD/ADHD

Yes No

Allergy to Latex/Metals

Yes No

Allergy to Plastic

Yes No

Any Hospital Stays

Yes No

Any Operations

Yes No

Asthma

Yes No

Cancer

Yes No

Congenital Heart Defect

Yes No

Convulsions/Epilepsy

Yes No

Diabetes

Yes No

Handicaps/Disabilities

Yes No

Hearing Impairment

Yes No

Heart Murmur

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

HIV+/AIDS

Yes No

Kidney/Liver Problems

Yes No

Psychological Counseling

Yes No

Rheumatic/Scarlet Fever

Yes No

Tuberculosis (TB)

Yes No

Please discuss any medical problems that the patient has had:

Does/Has the patient have/had any of the following habits?

Chew/Smoke Tobacco

Yes No

Clenching/Grinding Teeth

Yes No

Lip Sucking/Biting

Yes No

Mouth Breather

Yes No

Nail Biting

Yes No

Nursing Bottle Habits

Yes No

Speech Problems

Yes No

Thumb/Finger Sucking

Yes No

Tongue Thrust

Yes No

Signatures

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the dental staff to perform the necessary dental services I/my child may need.

This office 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 services of one or more credit reporting agencies.

If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

I understand that at the time of my office visit, my physical signature will be required to confirm the acknowledgements above.

The Parent or Guardian who accompanies the child is responsible for payment. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

Please check your form to make sure it is complete and press the submit button when you are done. You will see a confirmation page when your form has been successfully submitted. Thank you!

Patient /Guardian Signature:

Date