Patient Health History Form

Patient Health History Form

Save time at the orthodontic office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You may need to provide a signature at the office to verify that the information you submitted online is accurate.
Patient Information
Name*

First NameLast Name
I prefer to be called
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone/Other*
Please enter a valid phone number.
Email*
example@example.com
Birth date*

MonthDayYear
Date
Age
Gender

MaleFemale
Social Security Number (U.S. Only)
Whom may we thank for referring you to our office?
Other family members seen by us:
Responsible Party Information
Relationship to Patient
Full Name

First NameLast Name
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone/Other*
Please enter a valid phone number.
Email*
example@example.com
If patient is under 18, please complete this section.
Social Security Number (U.S. Only)
Birth date

MonthDayYear
Date
Employer
Occupation
Number of Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Social Security Number (U.S. Only)
Birth date

MonthDayYear
Date
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone/Other
Please enter a valid phone number.
Email
example@example.com
Dental Insurance Information
Insured's Name

First NameLast Name
Insured's Social Security Number (U.S. Only)
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Do you have dual coverage?

YesNo
Insured's Name

First NameLast Name
Insured's Social Security Number (U.S. Only)
Insurance Company
Group Number
Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Information
Name of nearest relative not living with you:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician
Date of Last Visit

MonthDayYear
Date
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication(s)?

YesNo
List any medications you are currently taking:
Are you allergic to any medication(s)?

YesNo
Comment
Do you have any history of any major illness?

YesNo
Comment
Have you had any major operations?

YesNo
Comment
Have you ever been involved in a serious accident?

YesNo
Comment

Please check any of the following that you have had or currently have:*

	Yes	No
Abnormal Bleeding/Hemophilia
ADD/ADHD
Anemia
Arthritis
Asthma or Hay Fever
Autism
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/AIDS
Kidney Problems
Latex or Metal Allergy
Pneumonia
Nervous Disorders
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor/Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?
Patients Under 18

If patient is under the age of 18, please answer the following questions:
Patient Height
Patient Weight
School
Grade
Has patient begun puberty?

YesNo
If patient is a girl, has menstruation begun?

YesNo
If patient is a boy, has their voice changed or have facial hair?

YesNo
Has the patient grown in the past year or has their shoe size changed recently?

YesNo
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you the most about your teeth? Do you like your smile?
Please check any of the following which apply to you, and add any relevant comments.
Are you presently in any dental pain?

YesNo
Comment
Have you ever experienced any unfavorable reaction to dentistry?

YesNo
Comment
Have you ever lost or chipped a tooth?

YesNo
Comment
Have there been any injuries to the face, teeth, or mouth?

YesNo
Comment
Is any part of your mouth sensitive to pressure?

YesNo
Comment
Do you have any type of thumb, finger, or tongue habits?

YesNo
Comment
Have you experienced bleeding gums?

YesNo
Comment
Do you have any speech problems?

YesNo
Comment
Are you a mouth breather?

YesNo
Comment
Have adenoids or tonsils been removed?

YesNo
Comment
Have you been notified of having any missing or extra permanent teeth?

YesNo
Comment
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

YesNo
Comment
Are you aware of your jaws clicking or popping?

YesNo
Comment
Are you aware of clenching your teeth during the day?

YesNo
Comment
Have you ever been told that you grind your teeth?

YesNo
Comment
Do you have 'tension' headaches?

YesNo
Comment
Have you ever experienced chronic ringing in your ears?

YesNo
Comment
By clicking the "Submit" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential, and is accessed only via a secure, encrypted interface.
Should be Empty:

Patient Health History Form

Patient Information

Responsible Party Information

Dental Insurance Information

Emergency Information

Medical History

Patients Under 18

Dental History