woodlandsvillagebraces.com - Health History Form

Health History Form
Please fill in this form completely down to the signature. The bottom boxed area is for office use. Thank you.
Patient Name:

First NameMiddle NameLast Name
Gender:
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Parent Name:

First NameLast Name
Driver’s License Number
Expiration

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about our office?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Please enter a valid phone number.Format: (000) 000-0000.
Privacy permission given to
Emergency Contact
Relationship
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
If Applicable: Who’s accompanying the child today?
Do you have legal custody of this child?
Person responsible for account
Occupation
Relationship
Email
example@example.com
Who is your general dentist?
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Last Visit
Who else has examined you?
PATIENT MEDICAL AND DENTAL HISTORY

SELECT ALL THAT APPLY
Women: pregnant, nursing?
Are you allergic to: Any metal, plastics, latex?

Other
Have you ever had: Check all that apply

Other
Other surgeries or hospitalizations?
Do you need to be pre-medicated?
Your health is:
Do you take any prescription drugs?
Which ones?
Bad experience whitening your teeth?
Are you allergic to: Aspirin, Dental Anesthetics, Penicillin, Erythromycin, Tetracycline, Codeine?
Do you grind your teeth?
Do you have any speech problems?
Have you ever had: Check all that apply
Do you sleep well regularly?
Do you breathe usually through your nose?
Have you had braces before?
Are you in braces now?
Have you had deep cleanings?
Sleep Apnea?
Snore?
TMJ Pain?
By signing here, I confirm that the information that I have given today is correct to the best of my knowledge.
Signature (patient / guardian)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please print your name
SAMPLE PHOTOS TO BE SENT BY TEXT
History / DX
Not to be treated
Concerns Prior to Tx
Tx Accepted
Records
Appt Made
Follow up with,
Should be Empty:

Health History Form

PATIENT MEDICAL AND DENTAL HISTORY

SAMPLE PHOTOS TO BE SENT BY TEXT