Health History Form

Health History Form

Save time by filling out your health history form online before your first appointment. Take a few minutes to fill out this form, click submit at the bottom, and your information will be sent to us with secure encryption.
Name *

First Name Last Name
I prefer to be called (nickname)
Patient's Birth Date *

Month Day Year
Date
Patient's Gender
Patient's Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best Phone Number for Appointment Reminders/Communication *

Area Code Phone Number
Whose phone number is listed above? *
Additional phone numbers

Area Code Phone Number
Whose phone number is listed above?
Best e-mail we can send information to if needed *
example@example.com
If the patient is a student, at what school and what grade?
RESPONSIBLE PARTY INFORMATION

Billing contact information
Who will be the financially responsible party for this patient? *
If the patient is a minor, please give the parent's or legal guardian's full name

First Name Last Name
Marital Status
Spouse's name

First Name Last Name
Mailing address if different from patient

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Occupation/Place of employment
Work phone number

Area Code Phone Number
Dental Insurance Information

We are happy to check on your orthodontic benefits for you. If you have dental insurance, please provide us with the following information. When you arrive for your first appointment, we will go over your orthodontic coverage with you.
Do you have dental insurance? (If yes, fill the rest of the following questions out. If no, please scroll down to the next section) *

YES NO
Insured's Name

First Name Last Name
Insured's Social Security Number/Member Number
Insured's Date of Birth

Month Day Year
Date
Insurance company name
Insured's employer
Group number
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone Number

Area Code Phone Number
If you have dual coverage, please provide the same information as above for the secondary insurance.

First Name Last Name
Insured's Social Security Number/Member Number
Insured's Date of Birth

Month Day Year
Date
Insurance company name
Insured's employer
Group number
Insurance Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Company Phone Number

Area Code Phone Number
Emergency Contact Information
Name of nearest relative not living with you:

First Name Last Name
Phone Number of relative

Area Code Phone Number
Relationship to patient
Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician Name
Physician Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Physician Phone

Area Code Phone Number
Please check any of the following that you have had or currently have:

Abnormal bleeding/hemophelia Anemia Arthritis Asthma or Hay Fever Bone disorders Congential Heart Defect Diabetes Dizziness Epilepsy Gastrointestinal Disorders Heart Problems Heart Murmur Hepatitis/liver problems Herpes High Blood Pressure HIV/AIDS Kidney Problems Nervous Disorders Pneumonia Prolonged Bleeding Radiation/Chemotheraphy Rheumatic Fever Tuberculosis Tumor/Cancer
If you're taking any medication, please list them below.
Are you allergic to any medications or to metals/latex?
Do you have a history or any major illness?
Have you had any major operations?
Dental History
Do you see a local dentist regularly? *

Yes No
If yes, who is your dentist?
Date of your last visit?
What concerns you most about your teeth?
Are you currently in any dental pain?

Yes No
Please elaborate
Have you ever experienced any unfavorable reaction to dentistry?

Yes No
Please elaborate
Have you ever lost or chipped any permanent teeth?

Yes No
Please elaborate
Have there been any major injuries to the face, mouth or teeth?

Yes No
Please elaborate
If any part of your mouth sensitive to pressure?

Yes No
Please elaborate
Do you have any type of thumb or tongue habit?

Yes No
Please elaborate
Are you a mouth breather?

Yes No
Please elaborate
Are you a mouth breather?

Yes No
Please elaborate
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

Yes No
Please elaborate
Do your jaws click or pop?

Yes No
Please elaborate
Do you clench your teeth?

Yes No
Please elaborate
Have you ever been told you grind your teeth?

Yes No
Please elaborate
Do you have tension headaches or chronic ringing in the ears?

Yes No
Please elaborate
Acknowledgement of Privacy Practices

Click the link below to view our privacy practices.
Photo Release Consent

We are proud of the beautiful smiles we create here at Peachtree City Orthodontics. If you select "yes" below, you are giving us consent to use your/your child's photograph in our office for internal use (pictures the wall, brochures, contests, etc), website and social media. It is understood that any permission granted at this time may be revoked by contacting our office.
Peachtree City Orthodontics has my permission to use my/my child's photo. *

Yes No
Should be Empty:

Health History Form

RESPONSIBLE PARTY INFORMATION

Dental Insurance Information

Emergency Contact Information

Medical History

Dental History

Acknowledgement of Privacy Practices

Photo Release Consent