Patient Name:
Date of Birth
Email address to confirm appointments:
Additional email address
DENTAL HISTORY
Yes
No
Do you have difficulty or pain when opening your mouth?
Yes
No
Do you hear noises in the jaw joints?
Yes
No
Have you ever had an injury to your jaw, head or neck?
Yes
No
Have you previously been treated for temporomandibular disorder (TMD, TMJ)?
Yes
No
Have you ever been treated for periodontal disease?
Yes
No
Have you ever sucked your thumb or fingers? If yes, until what age:
Yes
No
Do you have any speech problems?
Yes
No
Have any teeth been injured or chipped due to an accident?
Yes
No
Have you ever been informed of extra or missing permanent teeth?
Yes
No
Have you had any previous orthodontic consultation or treatment?
Yes
No
Does anyone in the family have a similar dental condition?
Yes
No
Would you mind wearing braces?
Yes
No
Do you have a condition requiring pre-medicating for dental procedures?
Medical History
Do you have or have you had any of the following diseases or medical problems? Please check (√).
Rheumatic fever
Stroke
Diabetes
High blood pressure
Rheumatic heart disease
Congenital heart disease
Fainting spells
Hepatitis/Liver diseases
Allergy
Sinus troubles
Arthritis
Arteriosclerosis
Cardiovascular disease
Asthma
Stomach Ulcers
Seizures
Heart attack
Hay fever
Kidney problems
Coronary occlusion
Tuberculosis
Yes
No
Are you now under the care of a physician? If yes, what is the condition being treated
Yes
No
Have you been hospitalized or had a serious illness within the past five years? lf yes, please explain:
Yes
No
Have you had abnormal bleeding associated with previous extractions, surgery or trauma?
Yes
No
Do you have any blood disorder (e.g. HIV, anemia)? If yes, please describe the blood disorder:
Yes
No
Do you have any disease, condition or problem not listed above that you think we should know about? If yes,please explain:
Yes
No
May we consult with your doctor, dentist or any previous health practitioner who may have knowledge of prior treatment, disease or illness ?
Yes
No
If you are a female, are you pregnant?
List any medications or substances (i.e., latex) to which you are allergic:
List all medications you are currently taking:
Primary Care Physician:
Dentist:
What was the approximate date of your last dental exam? :
Has anyone in your family been treated in our office?:
Who should we thank for referring you to our office?:
Who is financially responsible for this account?:
Reason for consultation and information desired:
Minor Patient
Address:
City:
State:
Zip code:
Home Telephone:
School:
Grade:
Father's Name:
SS#
Birth date
Address:
City:
State:
Zip code:
Home Telephone:
Cellphone:
Employer:
Occupation:
Work Telephone:
Orthodontic Insurance?
Yes
No
Insurance Company :
Group Number:
Policy Number:
Telephone:
Mother's Name:
SS#
Birth date
Address:
City:
State:
Zip code:
Home Telephone:
Cellphone:
Employer:
Occupation:
Work Telephone:
Orthodontic Insurance?
Yes
No
Insurance Company :
Group Number:
Policy Number:
Telephone:
Adult Patient
Address:
City:
State:
Zip code:
Home Telephone:
Cellphone:
SS#:
Spouse Name:
Employer:
Occupation:
Work Telephone:
Orthodontic Insurance?
Yes
No
Insurance Company :
Group Number:
Policy Number:
Telephone:
Please promptly inform this oflice of any changes in your medical or dental history.
I authorize the use of this signature on insurance forms and to release information necessary to secure payment.
Signature:
Date