New Patient Health History
Name
*
First Name
Last Name
Nickname
Birth Date
*
-
Month
-
Day
Year
Date
Age
Gender
*
Male
Female
Social Security #
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Cell Phone Carrier
*
Secondary Phone
Please enter a valid phone number.
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?
Building Sign
Internet
Family
Friend
Dentist
Insurance
Other
Financial Party Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
Please enter a valid phone number.
Cell Phone Carrier
*
Secondary Phone
Please enter a valid phone number.
Secondary Phone Type
Email
*
example@example.com
Social Security #
*
Employer
Occupation
Birth Date
-
Month
-
Day
Year
Date
Work Phone
Please enter a valid phone number.
Relationship to Patient
Do you have insurance that covers orthodontics? If so, please name the Insurance Company.
Dental History
Dentist Name
Last Dental Visit
-
Month
-
Day
Year
Date
Dentist Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.
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?
*
Yes
No
Grind or clench teeth?
*
Yes
No
Oral habits (thumb/finger habit, lip/nail biting)?
*
Yes
No
Injury to face, jaw, teeth or mouth?
*
Yes
No
Pain, tenderness, or noise in jaw?
*
Yes
No
Frequent headaches?
*
Yes
No
Neck/shoulder pain?
*
Yes
No
Frequent sore throats?
*
Yes
No
Brush teeth daily?
*
Yes
No
Floss teeth daily?
*
Yes
No
Fluoride treatments?
*
Yes
No
Mouth breathing?
*
Yes
No
Snores during sleep?
*
Yes
No
Requires premedication?
*
Yes
No
Any missing or extra permanent teeth?
*
Yes
No
Apprehensive about dental care?
*
Yes
No
Frequently chews gum?
*
Yes
No
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
*
Yes
No
Tuberculosis/Lung Disease
*
Yes
No
Pneumonia
*
Yes
No
Liver Disease
*
Yes
No
Kidney Disease
*
Yes
No
Heart Attack/Stroke
*
Yes
No
Heart Disease
*
Yes
No
Congenital Heart Defect
*
Yes
No
Heart Murmur
*
Yes
No
Hemophilia
*
Yes
No
Cancer
*
Yes
No
Family History of Cancer
*
Yes
No
Received Radiation Treatment
*
Yes
No
Growth Problems
*
Yes
No
Endocrine Problems
*
Yes
No
Hormone Therapy
*
Yes
No
Latex/Metal Allergy
*
Yes
No
Nervous Disorders
*
Yes
No
Bone Disorders/Bone Loss
*
Yes
No
Diabetes
*
Yes
No
Hypertension/High Blood Pressure
*
Yes
No
Prolonged Bleeding/Transfusion
*
Yes
No
Anemia
*
Yes
No
HIV/AIDS
*
Yes
No
Hepatitis
*
Yes
No
Tonsils/Adenoids Removed
*
Yes
No
Seizures/Epilepsy
*
Yes
No
Handicaps/Disabilities
*
Yes
No
Asthma
*
Yes
No
Arthritis
*
Yes
No
Treated for Emotional Problems
*
Yes
No
Ever Been Hospitalized
*
Yes
No
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 pubery?
Yes
No
If patient is a girl, has menstruation begun?
Yes
No
If patient is a boy, has their voice changed or have facial hair?
Yes
No
Has the patient grown in the past year or has their shoe size changed recently?
Yes
No
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
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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