PATIENT INFORMATION
Patient name
*
Gender
*
Male
Female
Social security number
Birth date
Driver’s license number
Home address
City
State
Zip
Primary phone
*
undefined
Home
Cell
Secondary phone
undefined
Home
Cell
Other
Email
*
example@example.com
Employer
Occupation
SPOUSE/PARTNER AND EMERGENCY CONTACT INFORMATION
Marital status
*
Single
Married
Divorced
Widowed
Significant other
Spouse/partner’s name
Primary phone
Address
City
State
Zip
Emergency contact name
Relation
Phone
Address
City
State
Zip
Person(s) OK to release appointment or medically related information to concerning you:
Name
Relation
Name
Relation
INSURANCE INFORMATION
Primary insurance company
Phone
Group number
Policy number
Member ID number
Policy holder’s name
Relation
Policy holder’s social security number
Policy holder’s birth date
Employer
Work phone number
Secondary insurance company
Phone
Group number
Policy number
Member ID number
Policy holder’s name
Relation
Policy holder’s social security number
Policy holder’s birth date
Employer
Work phone number
DENTAL HISTORY
General dentist
Last visit
How did you hear about our practice?
Ad
Internet
Family or friend
Physician
Other
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to accomplish?
Have you visited an orthodontist before?
Yes
No
When?
Reason?
Have your tonsils or adenoids been removed?
Yes
No
When?
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Have you ever had an injury to (select all that apply)
Teeth
Mouth
Chin
Do you have speech problems?
Yes
No
If so, explain
Do your gums bleed?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits?
Clenching/grinding teeth
Nail biting
Lip sucking/biting
Thumb/finger sucking
Mouth breathing
Chewing/eating problems
MEDICAL HISTORY
Are you currently being treated by a physician?
Yes
No
Reason
Physician
Last visit
Phone
Do you have any allergies/sensitivities to medications or latex?
Yes
No
Please list all allergies
Are you currently taking any prescription or over-the-counter medications?
Yes
No
Please list, with dosage
Has puberty and/or menstruation began?
Yes
No
N/A
Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?
Yes
No
Has your child had any operations or serious illnesses? If yes, describe
Has your child ever had a blood transfusion?
Yes
No
If yes, give approximate dates:
(Women) Are you pregnant?
Yes
No
Nursing?
Yes
No
Taking birth control pills?
Yes
No
Check if your child has or has ever had any of the following:
Anemia
Arthritis, Rheumatism
Artificial heart valves
Artificial joints
Asthma
Back problems
Blood disease
Cancer
Chemical dependency
Chemotherapy
Circulatory problems
Cortisone treatments
Cough, persistent
Coughing blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart murmur
Heart problems
Hemophilia
Hepatitis
High blood pressure
HIV/AIDS
Jaw pain
Kidney disease
Liver disease
Mitral valve prolapse
Pacemaker
Radiation treatment
Respiratory disease
Rheumatic fever
Scarlet fever
Shortness of breath
Skin rash
Stroke
Swelling of feet or ankles
Thyroid problems
Tobacco/vaping habit
Tonsillitis
Tuberculosis
Ulcer
Venereal disease
AUTHORIZATION
*
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient signature and/or responsible party
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: