Health History

Form
Patient's Name:

First NameLast Name
Preferred Name: your answer
Gender: your answer
Date of birth:  Date
Preferred language:
English   Spanish
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Email:
example@example.com
Preferred Contact Phone Number
Please enter a valid phone number.
Relatives treated at our office: Name Name Name
How did you hear about our office?     My dentist referred me
Friend     Name
Social Media   Google/Internet     Other   Your answer
If patient is an ADULT, please fill out this section:
Employed by:   Your answer
Spouse's name:   Your answer
Spouses employer:   Your answer
If patient is a MINOR, please fill out this section:
School:   Your answer
Grade:   Your answer
Father's name:   Your answer
Mother's name:   Your answer
Parent's marital status:
Father's employer:   Your answer

Mother's employer:   Your answer
Father's cell #:      Phone number
Mother's cell #:   Phone number
Is there any dental insurance we can check for you?

This must be completed to get an accurate financial quote
Yes No
Policyholder/Subscriber name:   First Name   Last Name
Birthdate:   Date
Relationship to patient:    Your answer
Insurance company name:   Your answer
Insurance company phone number:   Phone number
Member ID #:   Your answer
Subscriber's social security #:   Your answer
Employer:   Your answer

SECONDARY INSURANCE (if applicable)
Policyholder/Subscriber name:   First Name   Last Name
Birthdate:   Date
Relationship to patient:   Type a label
Insurance company name:Your answer
Insurance company phone number:   Area Code   Phone Number
Member ID#:   Type a label
Subscriber's social security #:   Type a label
Employer:   Type a label
Dental History
Dentist:  Your answer
Date of last visit:   Date
*What concerns you most about your teeth:   Your answer
*Do you have any type of thumb/finger or tongue habit?   Your answer
*Are you aware of any missing or extra teeth? Yes  No     If yes, explain
*Have you had any injuries to the teeth or jaws?   Yes   No     If yes, what/when?
*Have you had any previous orthodontic treatment?   Yes   No   If yes, when and with who?
Medical History
Physician:   Your answer
Date of last visit:   Date
*List any medications currently taking: Name of medications, or type "none" if none taken*

Please check yes or no (If yes, please explain):
*Have you ever taken any bone medications (bisphosphonates)?
Yes   No  Name of medication
*Do you have any allergies?
Yes   No   Your answer
*Do you need to pre-medicate with antibiotics?   Yes   No
*Any medical conditions that we should be aware of?   Yes   No    Your answer   Your answer   Your answer
*Are you a mouth breather?
Yes   No
*Do you snore or have sleep apnea?   Yes   No
*Have you had your tonsils and/or adenoids removed?   Yes   No
*Have you been seen by an ENT?     Yes   No
*Have you ever seen a speech/language pathologist or myofunctional therapist?
Yes   No
*Female patients only: Are you pregnant?   Yes   No
Check any of the medical conditions below that you have had or currently have:
I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or ommisions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will so inform this practice.
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Form

If patient is an ADULT, please fill out this section:

If patient is a MINOR, please fill out this section:

Is there any dental insurance we can check for you?

Dental History

Medical History