Language
English (US)
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Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Middle Name
Last Name
Birthdate
*
/
Month
/
Day
Year
Date
Parent/Guardian Name (if patient is under 18 years of age)
First Name
Last Name
Relationship to patient
Parent
Close relative
Other
If other, please indicate how you are related:
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Indicate type of phone (for # listed above):
*
Cell phone
Landline
Work
Other
Email
*
example@example.com
Emergency Contact
Name
*
First Name
Last Name
Relationship to patient:
*
Phone Number
*
-
Area Code
Phone Number
MEDICAL HISTORY
Any drugs or medication currently in use?
*
No
Yes
If yes, what? Please list.
*
Are you under a doctor's care?
*
No
Yes
If yes, why?
*
Is there any history of major illness?
*
No
Yes
If yes, what?
*
Are there any drug sensitivities?
*
No
Yes
If yes, please list:
*
Do you have any allergies? (including nickel sensitivity)
*
No
Yes
If yes, please list:
*
Are you sensitive to latex?
*
No
Yes
Do you have a tendency to colds, sore throats, or ear infections?
*
No
Yes
Do you smoke?
*
No
Yes
Do you have sleep apnea?
*
No
Yes
Do you snore?
*
No
Yes
Are you HIV positive?
*
No
Yes
Are you pregnant?
*
No
Yes
DENTAL HISTORY
Name of Dentist/Clinic:
*
Date of last exam:
/
Month
/
Day
Year
Date
Have there been any injuries to the face, mouth or teeth?
*
No
Yes
Have you ever had speech therapy?
*
No
Yes
Are you a mouth breather?
*
No
Yes
Were you or are you currently a thumb sucker?
*
No
Yes
Have any teeth been extracted?
*
No
Yes
If yes, why?
Have you had any adverse effect to dental anesthesia?
*
No
Yes
Have you been treated for gum disease?
*
No
Yes
Have you had previous orthodontic treatment or consultation?
*
No
Yes
If yes, when?
Do you play any musical instrument?
*
No
Yes
If yes, what type?
Do you clench or grind your teeth?
*
No
Yes
Does your jaw click or pop?
*
No
Yes
Is there difficulty opening wide?
*
No
Yes
Does your jaw ever stick so you can't close?
*
No
Yes
Does it hurt to chew?
*
No
Yes
Is there pain in front of your ears?
*
No
Yes
Is there cheek or temple pain?
*
No
Yes
Do you suffer from headaches?
*
No
Yes
Do you have neck or shoulder pain?
*
No
Yes
What are your concerns about your teeth or jaw?
*
I have completed this form to the best of my knowledge.
Signature
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/
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Date
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