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
Male
Female
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?
*
Mom cell
Dad cell
Patient
Grandmother
Grandfather
Step mom
Step dad
Other
Additional phone numbers
-
Area Code
Phone Number
Whose phone number is listed above?
Mom cell
Dad cell
Patient
Grandmother
Grandfather
Step mom
Step dad
Other
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?
*
Self
Mother
Father
Grandmother
Grandfather
other
If the patient is a minor, please give the parent's or legal guardian's full name
First Name
Last Name
Marital Status
Married
Divorced
Widowed
Separated
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
Submit
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