Patient Information & Health History
Confidential Patient Information
Name
*
First Name
Last Name
Nickname
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Type
*
Please Select
Home
Cell
Work
Phone Number
*
Please enter a valid phone number.
Phone Type
Please Select
Home
Cell
Work
Phone Number
Please enter a valid phone number.
Email
*
example@example.com
Social Security #
If patient is a minor, please provide the Parent or Guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any family or friends who currently receive services of the practice:
List any of the patient's sports, hobbies, or musical instruments played:
How did you hear about our practice?
*
Financial Party Information
Name
*
First Name
Last Name
Marital Status
Please Select
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient
Please Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long at this address?
Previous Address (if less than 3 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Type
*
Please Select
Home
Cell
Work
Phone Number
*
Please enter a valid phone number.
Phone Type
Please Select
Home
Cell
Work
Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security #
*
Employer
*
Occupation
*
Length of Employment
*
Spouse or Other Parent's Name
First Name
Last Name
Relationship to Patient
Please Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #
Birthdate
-
Month
-
Day
Year
Date
Employer
Occupation
Length of Employment
Work Phone Number
Please enter a valid phone number.
Dental Insurance Information
Do you have dental coverage?
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's DOB
-
Month
-
Day
Year
Date
Relationship to Patient
Please Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer
Insurance Company
Subscriber ID #
Group #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.
Do you have dual dental coverage?
*
Yes
No
Policy Holder's Name
First Name
Last Name
Policy Holder's DOB
-
Month
-
Day
Year
Date
Relationship to Patient
Please Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer
Insurance Company
Subscriber ID #
Group #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.
Dental History
Dentist Name
*
Check-Up Frequency
Please Select
Once per Year
Twice per Year
More Than Twice per Year
Never
Emergencies Only
Last Dental Visit
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
Does patient need to pre-medicate with antibiotics prior to their dental visit?
*
Yes
No
Does the patient brush daily?
Yes
No
Does the patient floss daily?
Yes
No
What is the patient's main orthodontic concern?
Please check any of the following that apply to the patient:
Speech Problems/Therapy?
Clench or Grind Teeth?
Oral Habits (e.g., Thumb/Finger Sucking, Lip/Nail Biting)?
Injury to Face, Jaw, Teeth, or Mouth?
Discomfort from Teeth or Gums?
Pain, Tenderness, or Noise in Either Jaw?
Frequent Headaches?
Neck/Shoulder Pain?
Frequent Sore Throats?
Chipped or Injured Permanent Teeth?
Teeth Sensitivity to Hot or Cold?
Previous Root Canal Therapy?
Bad Taste/Mouth Odor?
Previous Periodontal (Gum) Treatment?
Abnormal Swallowing (Tongue Thrust)?
Teeth that Irritate the Tongue, Cheek, Lip, etc.?
Numerous Fillings?
Fluoride Treatments?
Mouth Breathing?
Snoring During Sleep?
Any Missing or Extra Permanent Teeth?
Apprehensive to Dental Care?
Frequently Chews Gum?
Thumb or Finger Habit as a Child?
Jaw Fractures, Cysts, or Mouth Infections?
Bleeding Gums?
Other Periodontal (Gum) Problems?
Frequent Canker Sores or Cold Sores?
Have the Wisdom Teeth been Removed?
Problems with Food Trapped Between Teeth?
Is All Dental Work Completed at This Time?
If any of the above were selected, please explain:
Has the patient had a TMJ screening?
Yes
No
Does the patient have a history of jaw joint problems?
Yes
No
Has the patient been treated for "TMJ"?
Yes
No
Does the patient notice clicking or popping in their jaw joint?
Yes
No
Does the patient clench their teeth?
Yes
No
Has the patient's jaw ever locked?
Yes
No
Does the patient have difficulty chewing or opening their mouth?
Yes
No
Does the patient's bite feel uncomfortable or unusual?
Yes
No
Does the patient experience soreness in the muscles of their face or around their ears?
Yes
No
If you answered "Yes" to any of the above questions, please explain:
Medical History
Physician Name
Date of Last Physical
Patient Health
Please Select
Good
Excellent
Fair
Poor
Has there been any change in the patient's general health within the last year?
*
Yes
No
Is the patient now under the care of a physician (other than routinely)?
*
Yes
No
If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years?
*
Yes
No
If so, what was the reason?
List any medications currently being taken by the patient (including non-prescriptive ones):
List any drug allergies the patient may have:
Does the patient have any of the following conditions? Check all that apply?
Heart Murmur
Damaged or Artificial Heart Valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood Disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint Problems
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Chemotherapy or Radiation Treatment
Thyroid / Endocrine Problems
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Sexually Transmitted Disease
Take Bisphosphonates (Fosamax, Boniva)
If any of the conditions above were selected, please explain:
Patient Under 18
If the patient is under the age of 18, please answer the following questions:
Height
Weight
School
Grade
Has the patient begun puberty?
Yes
No
If the patient is a girl, has menstruation begun?
Yes
No
If the 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
Has either of the patient's biological parents ever had orthodontic treatment?
Please Select
Yes
No
Don't Know
Submit
Should be Empty: