Patient Information & Health History Form

Patient Information & Health History
Confidential Patient Information
Name

First NameLast Name
Nickname
Birthdate

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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 NameLast Name
Marital Status
Relationship to Patient
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Social Security #
Employer
Occupation
Length of Employment
Spouse or Other Parent's Name

First NameLast Name
Relationship to Patient
Social Security #
Birthdate

MonthDayYear
Date
Employer
Occupation
Length of Employment
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance Information
Do you have dental coverage?
Policy Holder's Name

First NameLast Name
Policy Holder's DOB

MonthDayYear
Date
Relationship to Patient
Policy Holder's Employer
Insurance Company
Subscriber ID #
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual dental coverage?
Policy Holder's Name

First NameLast Name
Policy Holder's DOB

MonthDayYear
Date
Relationship to Patient
Policy Holder's Employer
Insurance Company
Subscriber ID #
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Dental History
Dentist Name
Check-Up Frequency
Last Dental Visit
Has the patient had an orthodontic consult or treatment?
If so, when?
Does patient need to pre-medicate with antibiotics prior to their dental visit?
Does the patient brush daily?
Does the patient floss daily?
What is the patient's main orthodontic concern?
Please check any of the following that apply to the patient:
If any of the above were selected, please explain:
Has the patient had a TMJ screening?
Does the patient have a history of jaw joint problems?
Has the patient been treated for "TMJ"?
Does the patient notice clicking or popping in their jaw joint?
Does the patient clench their teeth?
Has the patient's jaw ever locked?
Does the patient have difficulty chewing or opening their mouth?
Does the patient's bite feel uncomfortable or unusual?
Does the patient experience soreness in the muscles of their face or around their ears?
If you answered "Yes" to any of the above questions, please explain:
Medical History
Physician Name
Date of Last Physical
Patient Health
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routinely)?
If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years?
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?
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?
If the patient is a girl, has menstruation begun?
If the patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either of the patient's biological parents ever had orthodontic treatment?
Should be Empty:

Patient Information & Health History

Confidential Patient Information

Financial Party Information

Dental Insurance Information

Dental History

Medical History

Patient Under 18