Frederick S. Fritz Child Health History

Frederick S. Fritz Adult Health History

We would like to welcome you and your child to our office! In an effort to provide the best service possible, we ask you to fill out this form as completely as possible. Please give us a call if you have any questions. Thank you!
Patient Information
Patient Name: *
Preferred Pronoun:*

HeSheNon-binary/they
Birth Date:*

MonthDayYear
Date
Gender:*
SSN:
Driver's License #
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number:*
Please enter a valid phone number.
Secondary Phone Number:*
Please enter a valid phone number.
Email:*
example@example.com
Employer:
Occupation:
Spouse/Emergency Contact
Name:*

First NameLast Name
Relationship to Patient:*
Primary Phone: *
Please enter a valid phone number.
Secondary Phone:
Please enter a valid phone number.
Check this box if your address is the same as the patient's address. Otherwise, please fill in your address below.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any other people to whom it is okay to release appointment and medical information.
Dental Insurance Information
If you do not have dental insurance, please check this box and skip this section.

I do not have dental insurance.
Primary Dental Insurance Company
Phone Number
Please enter a valid phone number.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.
Co-pay
Deductible
Primary Dental Insurance Company
Phone Number
Please enter a valid phone number.
Group Number
Policy Number
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Employer
Work Phone
Please enter a valid phone number.
Co-pay
Deductible
Health History
General Dentist
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for Last Visit
Date of Last Visit

MonthDayYear
Date
How did you hear about us?

AdInternetFamily or friend referralPhysician of dentist referralOther
Name of referring person
Have we treated other family members?

YesNo
Details:
What are the main concerns you'd like orthodontics to address?
Have you visited an orthodontist before?*

YesNo
Have your tonsils or adenoids been removed?*

YesNo
Have you ever experienced jaw joint pain or discomfort (TMJ/TMD)?*

YesNo
Do you have any missing or extra permanent teeth?*

YesNo
Do you have speech problems?*

YesNo
Do you like your smile?*

YesNo
Do you smoke?*

YesNo
Do your gums bleed?*

YesNo
Have you ever had an injury to any of the following?*

TeethMouthChinNone of the above.
Do you currently have or have you ever had any of the following habits?*

Clenching or grinding teethMouth breathingThumb or finger suckingLip sucking or bitingNail bitingProlonged pacifier useTongue thrustingNone of the above.
Physician: *
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason for last visit: *
Date of last visit: *

MonthDayYear
Date
Do you have any allergies or sensitivities to medications or latex?

YesNo
Are you currently taking any medications?

YesNo
Please describe any medical conditions that are currently being treated.
Has you had any serious illnesses or operations?

YesNo
Details:
Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine).

YesNo
Check if you have or have ever had any of the following:

AnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStrokeSwelling of Feet or AnklesHtyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal DiseaseNone of the Above
The following questions are for females only:
Are you pregnant?

YesNo
Are you nursing?

YesNo
Are you on hormonal birth control?

YesNo
Authorization
I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical information.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Frederick S. Fritz Adult Health History

Patient Information

Spouse/Emergency Contact

Dental Insurance Information

Health History

Authorization