Patient Name

Nickname

Date of Birth:

School (if applicable):

Address:

ZIP Code:

Email:

Gender:

MaleFemaleOther

Patient/Parent Phone #1:

Patient/Parent Phone #2:

Emergency Contact Name:

Emergency Contact Phone#:

Responsible Parties Name:

Address:

Employer-Occupation:

Bus, Phone:

Responsible Parties Name:

Address:

Employer-Occupation:

Bus, Phone:
Responsible Parties Name:

Address:

Employer-Occupation:

Bus, Phone:

Orthodontic Insurance:

Referred By:

Dentist:

Physician - Pediatrican:

Front of insurance card

Back of insurance card

Primary Insurance:

Insurance Company Name:

Subscriber Name:

Insurance ID:

Insurance Address:

Insurance Phone Number:

Subscriber DOB:

SS#:

Secondary Insurance:

Insurance Company Name:

Subscriber Name:

Insurance ID:

Insurance Address:

Insurance Phone Number:

Subscriber DOB:

SS#:

MEDICAL HEALTH HISTORY

THANK YOU for taking the time to provide us with this essential information. It will be used each time we select the safest and most effective means of providing you with dental care. Of course all information on this form is completely confidential.

Please describe your present health
Excellent Good Fair Poor
Has your present health changed in the last year?
Yes No
Have you ever been hospitalized for illness or surgery?
Yes No
Has a doctor treated you for any condition in the last 2 years?
Yes No
Are you allergic to any drugs or substances?
Yes No
Have you ever experienced bleeding that was difficult to stop?
Yes No
Has anyone in our family ever had Diabetes?
Yes No
Are you required to restrict your work or activity?
Yes No
Is your diet restricted or specially prescribed?
Yes No
Are you taking ANY MEDICATIONS?
Yes No

If so, please list with dosage:

Please indicate yes or no for any condition even if you no longer have them:

Heart Murmur

Yes No

Heart Surgery

Yes No

Rheumatic Fever

Yes No

Congenital Heart Lesions/Defects

Yes No

Heart Pacemaker

Yes No

Heart Valve Prosthesis

Yes No

Heart Attack

Yes No

Chest Pains

Yes No

High Blood Pressure

Yes No

Low Blood Pressure

Yes No

Hardening of Arteries

Yes No

Shortness of Breath on Mild Exertion

Yes No

Hives/Rash

Yes No

Hay Fever

Yes No

Recurrent Illness

Yes No

Arthritis

Yes No

Hepatitis

Yes No

Jaundice

Yes No

Diabetes

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Persistent Cough

Yes No

Asthma

Yes No

Lung Disease

Yes No

Tuberculosis

Yes No

Bronchitis

Yes No

Frequent Colds/Sore Throats

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting

Yes No

Anemia/Blood Disease

Yes No

Tumors/Growths

Yes No

Treated for Emotional Problems

Yes No

Frequent Headaches

Yes No

Nervous/Anxious

Yes No

Take Bisphosphonates

Yes No

Any Recent Unintentional Weight Changes

Yes No

Sinus Trouble

Yes No

Artificial Joints

Yes No

Swollen Glands

Yes No

Immune System Problems

Yes No

Sexually Transmitted Infection

Yes No

Thyroid/Parathyroid Disorders

Yes No

Cancer Treatments

Yes No

HIV/AIDS

Yes No

Ulcers

Yes No

Stroke

Yes No

IF FEMALE, ARE YOU?

Pregnant

Yes No

On Birth Control Pills

Yes No

In or Past Menopause

Yes No

If you answered yes to any of the above questions please provide details, including a list of any known allergies.

Dental History:

Last Dental Examination:

Prior Orthodontics(other children):

What is Your Chief Complaint about Patient's Teeth:

Does the Patient Mouth Breathe or Nose Breathe(snore at night):

Is there any history of dental trauma or any other medical/dental problem that we should know about?

PATIENT SIGNATURE (or Parent or Guardian if patient is a Minor)

Please use your mouse to sign this

DATE:

REVIEWED BY: