New Patient Health History

New Patient Health History
Name

First NameLast Name
Nickname
Birth Date

MonthDayYear
Date
Age
Gender
Social Security #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Carrier
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type
Email
example@example.com
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
How did you hear about our office?
Financial Party Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Carrier
Secondary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Type
Email
example@example.com
Social Security #
Employer
Occupation
Birth Date

MonthDayYear
Date
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
Do you have insurance that covers orthodontics? If so, please name the Insurance Company.
Dental History
Dentist Name
Last Dental Visit

MonthDayYear
Date
Dentist Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Check-up Frequency
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient’s main orthodontic concern?
Speech problems/therapy?
Grind or clench teeth?
Oral habits (thumb/finger habit, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Pain, tenderness, or noise in jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently chews gum?
If any of the above dental questions were answered “Yes,” please explain:
Medical History
Physician Name
Patient Health
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
If any of the above medical questions were answered “Yes,” please explain:
Patients Under 18
Please list the name and birth date of any siblings:
Height
Weight
School
Grade
Father/Guardian 1 Name
Mother/Guardian 2 Name
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or do they have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Liability

I understand that the information that I have given today is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. If this office accepts my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible(s) that my insurance does not cover.
Signature
Today's Date

MonthDayYear
Date
Should be Empty:

New Patient Health History

Financial Party Information

Dental History

Medical History

Patients Under 18

Liability