Patient Information
Today's Date
-
Month
-
Day
Year
Patient's Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Cell
-
Area Code
Phone Number
Emergency Contact Cell
-
Area Code
Phone Number
Social Security#
Birthdate
-
Month
-
Day
Year
Age
If patient is a minor, give parent's or guardian's name
First Name
Last Name
Whom may we thank for referring you to our office?
Responsible Party Information
Name
First Name
Middle Name
Last Name
Marital status
Residence
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address
Home phone
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Previous Address (if less then 3 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Responsible Party's Birthdate
-
Month
-
Day
Year
Social Security#
Relationship to Patient
Employer
Occupation
No. of years Employed
Spouse's Name
First Name
Last Name
Relationship to Patient
Employer
Occupation
No. years Employed
Social Security#
Birthdate
-
Month
-
Day
Year
Work Phone
-
Area Code
Phone Number
Insurance Information
Insurance Subscriber Name
First Name
Last Name
Insured Soc.Sec.#
Insurance Subscriber's Date of Birth
-
Month
-
Day
Year
Date
Insurance Company
Group No.
Local No.
Insurance Co.Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Do you have dual coverage?
Yes
No
Insured's Name
First Name
Last Name
Insured Soc.Sec.#
Insurance Company
Group No.
Local No.
Insurance Co.Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Insured's Employer
First Name
Last Name
Emergency Information
Name of nearest relative not living with you
First Name
Last Name
Complete Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
-
Area Code
Phone Number
I understand that where appropriate,credit bureau reports may be obtained.
Signature (Parent signature if minor)
Date
-
Month
-
Day
Year
Initials
Back
Next
Patient's Name
First Name
Last Name
Nick Name
Sex
Male
Female
School
Grade
Interests
Names of children in family
Rows
Name
Age
1
2
3
4
5
6
General Dentist
Date of last dental exam
-
Month
-
Day
Year
Referred by
Physician
Medical History
Are you in good health?
Yes
No
Do you have the history of major illness?
Yes
No
Please List:
Check any of the following for which you have been treated:
Diabetes
Pneumonia
Heart trouble
Reumatic Fever
Bone disorders
Anemia
Epilepsy
Asthma
Kidney problem
Tuberculosis
Hepatitis
Liver involvement
Prolonged bleeding
Fainting/Dizziness
Nervous disorder
Osteoporosis/Osteopenia
Other
Have tonsils and adenoids been removed:
Yes
No
At what age?
List any drugs or medication now being taken. Give reason
List any allergies or drug sensitivity:
Dental History
Have you had any injuries to the face, mouth or teeth?
Yes
No
If yes
Have you ever sucked your finger or thumb?
Yes
No
(If yes) what age?
Do you have any speech problems?
Yes
No
If yes
Have you had speech therapy lessons?
Yes
No
If yes
Are you a mouth breather?
Yes
No
While awake
While sleep
Have you been told of any missing or extra teeth?
Yes
No
If yes
Do you have sensitive teeth?
Yes
No
If yes
Do you grind or clench your teeth?
Yes
No
If yes
Do you have cracking or clicking in your jaw joint?
Yes
No
When did it start?
Does your jaw ever lock on you?
Yes
No
Open or closed?
Do you have headaches?
Yes
No
How frequently?
Possible cause?
Do you have stiff necks?
Yes
No
How frequently?
Possible cause?
Do you have ear aches or clogged ears?
Yes
No
Possible cause?
Do antibiotics help?
Do your jaw muscles tire quickly while chewing?
Yes
No
If yes
Do you ever get knots or cramps in youe jaw muscles?
Yes
No
If yes
Primary Dentist Name
First Name
Last Name
Location
Have you had previous orthodontic treatment?
Yes
No
Orthodontist's Name
First Name
Last Name
Location
Have you consulted an orthodontist before?
Yes
No
Orthodontist's Name
First Name
Last Name
Location
Have any of your children had orthodontic treatment?
Yes
No
Orthodontist's Name
First Name
Last Name
Location
Has either parent had orthodontic treatment?
Yes
No
Orthodontist's Name
First Name
Last Name
Location
Do you have friends that are present or past patient of ours?
Yes
No
Names
Please give your reason for the consultation
Submit
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