Health History Form

Health History Form
PATIENT INFORMATION
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Social Security #:
If patient is minor, give parent or guardian’s name:
Patient Email:
example@example.com
Responsible Party Email:
example@example.com
RESPONSIBLE PARTY INFORMATION
Name:
Marital Status:
Residence Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this address?
Home Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Previous Address(if less than 3 years):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security #:
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient:
Employer:
Occupation:
Number of years employed:
Spouse’s Name:

First NameLast Name
Relationship to Patient:
Spouse’s Employer:
Spouse’s Occupation:
Number of years employed(Spouse’s):
Spouse’s Social Security #:
Spouse’s Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Information
Do you have insurance coverage?
Insured's Name:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's SSN:
Insurance Company:
Group #:
Local No.:
Insurance Co. Address:
Do you have dual coverage?
If Yes, please continue
Insured's Name:
DOB:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's SSN:
Insurance Company:
Group #:
Local No.:
Insurance Co. Address:
Insured's Employer:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Dental History
What are the main concerns that you would like orthodontics to accomplish?
Has patient had previous orthodontic treatment? Please describe:
What type of braces would like?
Have there been any injuries to the face, mouth, teeth or chin?
Chipped or injured primary or permanent teeth?
Has patient ever been informed of any missing or extra permanent teeth?
Has patient ever experienced pain/tenderness in his/her jaw joint(TMJ/TMD)?
Physician Name:
Physician Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Is patient currently under the care of a physician?
Please list all drugs, including over-the-counter medications that the patient is currently taking:
Please list all drug that the patient is allergic to:
Does patient have any of the following habits?

Other major illnesses?
For patient under 18 only:
Has puberty begun?
Has menstruation begun?
How does patient feel about orthodontic treatment?
Medical History
Has patient experienced any of the following medical problems?

None of the above
Has your child ever taken oral or intravenous bisphosphonates for bone disorders or cancer?
Do you take antibiotic premedication before any dental procedures?
Have you noticed any unusual changes in your child’s face or jaws?
Please discuss any medical problems that the patient has had:
Release and Waiver
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that it is my responsibility to inform this office of any changes in patient's medical status. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical health. I authorize the dental staff to perform any necessary dental/orthodontic services I or my child need.
Signature
Patient, Parent or Legal Guardian Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Health History Reviewed By:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

Insurance Information

If Yes, please continue

Emergency Information

Dental History

For patient under 18 only:

Medical History

Release and Waiver

Signature