CONFIDENTIAL

Date*

Date

Name*

First nameMiddle initialPatient's Last name

I prefer to be called

Birth date*

Date

MaleFemale

MaleFemaleOther

What are your preferred pronouns?

Home Address*

City, State, Zip code*

Cell phone*

Format: (000) 000-0000.

E mail address*

example@example.com

Spouse or closest relative's name(s)*

Relationship to patient*

Address (if different than patient address)

Cell phone*

Format: (000) 000-0000.

Patient's Dentist

Address, City, State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen:

Name

City, State

Reason

What concerns you about your teeth?*

Who suggested that you might need orthodontic treatment? *

Why did you select our office?*

Have you had any previous orthodontic treatment? Please describe.*

Have any other family members been treated in this office? Please name them.*

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.*

Who is financially responsible for this account?*

Address*

Address

Street Address Line 2

City, State, Zip

Cell phone*

Format: (000) 000-0000.

E mail address*

example@example.com

Primary policy holder's full name

Birth date

Date

Relationship to patient

ID #

Group #

YESNO

Secondary policy holder's full name

Birth date

Date

Relationship to patient

ID #

Group #

YESNO

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand dk/u

Now or in the past, have you had:

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

yesnodk/u

If yes, please explain

Have you had allergies or reactions to any of the following:

yesnodk/u

YesNo

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe.*

Do you or have you ever had a substance abuse problem? Please describe.*

yesno

If yes, what is the frequency?

yesno

If yes, what is the frequency?

Have you noticed any changes in your face or jaws?*

Any other physical problems?*

How often do you brush?*

How often do you floss?*

yesno

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders*

Diabetes*

Arthritis*

Severe allergies*

Unusual dental problems*

Jaw size imbalance*

Other family medical conditions?*

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Signature*

Date*

Date

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her 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 or dental health.

Signature*

Date*

Date

CONFIDENTIAL

Financial

Dental Insurance

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER