BRENT HOGGAN ORTHODONTICS
PATIENT INFORMATION
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Preferred Name
Sex (M/F)
Birthday
-
Month
-
Day
Year
Date
Age
*
*
Address
Street Address Line 2
City
State / Province
Zip
Home Phone
*
Format: (000) 000-0000.
Cell Phone/Pager
*
Format: (000) 000-0000.
School
Activities
RESPONSIBLE PARTY INFORMATION
Name
*
First Name
Last Name
*
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Format: (000) 000-0000.
Cell Phone/Pager
Format: (000) 000-0000.
Email
Driver License
Occupation
Martial Status
*
Married
Divorced
Single
Separated
Work Phone
*
Format: (000) 000-0000.
Work Phone
O.K. to contact at work?
Name of Spouse
Spouse Occupation
Spouse Work Phone
Format: (000) 000-0000.
Spouse Work Phone
O.K. to contact at work?
Name of Former Spouse (if divorced)
Address
Street Address Line 2
City
State / Province
Zip
Home Phone
Format: (000) 000-0000.
Cell Phone/Pager
Format: (000) 000-0000.
Email
example@example.com
INSURANCE INFORMATION
Insurance Company
Insurance Co. Phone
Format: (000) 000-0000.
Address
SS# or ID#
Employer Name
Group #
Insured’s Name
Insured's Birthday
-
Month
-
Day
Year
Date
Benefits
Are you aware that some appointments will infringe on school time?
*
Yes
No
Patient Name
*
Heart problems / murmurs?
*
Yes
No
High blood pressure?
*
Yes
No
Low blood pressure?
*
Yes
No
Circulatory problems?
*
Yes
No
Anemia?
*
Yes
No
Bleeding disorder?
*
Yes
No
Hemophilia?
*
Yes
No
Prosthetic heart valve?
*
Yes
No
Pacemaker?
*
Yes
No
Diabetes?
*
Yes
No
Kidney problems?
*
Yes
No
Liver disorders
*
Yes
No
Hepatitis?
*
Yes
No
Asthma?
*
Yes
No
Arthritis?
*
Yes
No
Stroke?
*
Yes
No
Rheumatic Fever?
*
Yes
No
Scarlet Fever
*
Yes
No
Measles
*
Yes
No
Mumps
*
Yes
No
Chicken Pox
*
Yes
No
Tuberculosis?
*
Yes
No
Tonsillitis
*
Yes
No
Sinus problems?
*
Yes
No
Ulcer
*
Yes
No
AIDS / HIV
*
Yes
No
STD?
*
Yes
No
Speech/hearing disorder?
*
Yes
No
Learning disorder?
*
Yes
No
Autism?
*
Yes
No
Psychiatric care?
*
Yes
No
Headaches
*
Yes
No
Epilepsy or seizures?
*
Yes
No
Osteorosis?
*
Yes
No
Osteopenia?
*
Yes
No
Allergies (list below)
*
Yes
No
Other
List any allergies
List any drugs or medications you are taking
Notes
Notes - Line 2
Are you pregnant?
Yes
No
Do you smoke or chew tobacco?
*
Yes
No
Have you previously consulted an orthodontist?
*
Yes
No
CHILDREN UNDER TWELVE
Has the patient ever sucked a thumb or finger?
Yes
No
If so, until what age?
Does the patient breath through the mouth while awake?
Yes
No
Does the patient breathe through the mouth while asleep?
Yes
No
Does the patient snore?
Yes
No
Does the patient want his or her teeth straightened?
Yes
No
Dental pain?
Yes
No
Bleeding gums?
Yes
No
Periodontal disease?
Yes
No
Grinding or clenching the teeth?
Yes
No
Congenitally missing teeth?
Yes
No
Extra permanent teeth?
Yes
No
Extracted permanent teeth
Yes
No
Sores in mouth of lips
Yes
No
Injury to mouth or face?
Yes
No
Jaw popping, clicking or pain?
Yes
No
Difficulty chewing?
Yes
No
Speech problems?
Yes
No
Notes
Notes - Line 2
Do you have a family history of missing teeth?
*
Yes
No
Do you have a family history of impacted teeth?
*
Yes
No
What is your main reason for seeking an orthodontic evaluation?
How did you hear about us?
*
Date of last dental examination
/
Month
/
Day
Year
Date
Patient’s dentist
*
Date of last physical examination
/
Month
/
Day
Year
Date
In case of emergency notify
*
Phone number
*
Format: (000) 000-0000.
Nearest relative
*
Responsible Party signature
*
Phone number
*
Format: (000) 000-0000.
Date
*
/
Month
/
Day
Year
Date
Doctor's Signature
Date
/
Month
/
Day
Year
Date
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