Health History Form
YOUR LEGAL NAME
*
First Name
Last Name
PREFERRED NAME
DOB
*
-
Month
-
Day
Year
Date
GENDER
*
INTERESTS
REFERRED BY
PAST/PRESENT FAMILY IN TREATMENT AT OUR OFFICE?
PLEASE LIST NAMES
EMAIL
*
example@example.com
MARITAL STATUS/SPOUSE'S NAME
PHONE
*
Please enter a valid phone number.
ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMPLOYER
*
OCCUPATION
*
RESPONSIBLE PARTY INFORMATION
NAME
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
MARITAL STATUS/SPOUSE'S NAME
EMAIL
example@example.com
PHONE
Please enter a valid phone number.
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
EMPLOYER
OCCUPATION
DENTAL INSURANCE INFORMATION
DO YOU HAVE DENTAL INSURANCE COVERAGE?
*
YES
NO
INSURANCE COMPANY
*
SUBSCRIBER NAME
*
DOB
*
-
Month
-
Day
Year
Date
SUBSCRIBER SSN
*
MEMBER ID
*
EMPLOYER
*
GROUP NUMBER
*
INSURANCE ADDRESS
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
INSURANCE PHONE
*
Please enter a valid phone number.
DO YOU HAVE ADDITIONAL INSURANCE COVERAGE?
*
YES
NO
INSURANCE COMPANY
SUBSCRIBER NAME
DOB
-
Month
-
Day
Year
Date
SUBSCRIBER SSN
MEMBER ID
EMPLOYER
GROUP NUMBER
INSURANCE ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
INSURANCE PHONE
Please enter a valid phone number.
MEDICAL INFORMATION/HISTORY
DENTIST
*
LAST CLEANING
*
-
Month
-
Day
Year
Date
PHYSICIAN NAME
*
LAST EXAM
*
-
Month
-
Day
Year
Date
PLEASE CHECK ALL THAT APPLY
*
FLOSSES DAILY
BRUSHES AT LEAST TWICE DAILY
GUMS BLEED
N/A
PLEASE INDICATE IF YOU HAVE (PLEASE CHECK ALL THAT APPLY)
*
BEEN EVALUATED FOR ORTHO TREATMENT BEFORE
UNDERGONE ORTHODONTIC TREATMENT WITH BRACES OR ALIGNERS
EVER RECEIVED AN INJURY TO THE FACE, MOUTH, TEETH, OR CHIN
HAD ADENOIDS/TONSILS REMOVED
BEEN INFORMED ABOUT MISSING OR EXTRA PERMANENT TEETH
BEEN TOLD TO TAKE ANTIBIOTICS PRIOR TO DENTAL VISITS
HAD PROBLEMS WITH PREVIOUS DENTAL WORK
N/A
CURRENTLY TAKING OR EVER TAKEN A BISPHOSPHONATE? INCLUDES ANY MEDICATION USED TO MAKE BONES STRONGER, SUCH AS
*
BONIVA
ACTONEL
FOSAMAR
N/A
OTHER
PLEASE CHECK ANY HABITS YOU HAVE
*
CLENCHING/GRINDING TEETH
LIP SUCKING/BITING
MOUTH BREATHING
NAIL BITING
SPEECH PROBLEM/SPEECH THERAPY
THUMB/FINGER SUCKING
TONGUE THRUST
EXCESSIVE SNORING
N/A
LIST MEDICATIONS CURRENTLY TAKING AND REASON
*
ANY ALLERGIES OR REACTIONS TO ANY OF THE FOLLOWING
*
ASPIRIN, TYLENOL, IBUPROFEN
LATEX
METALS
PLASTIC OR VINYL
SULFA DRUGS
CODEINE OR OTHER NARCOTICS
LOCAL ANESTHETICS
PENICILLIN OR OTHER ANTIBIOTICS
SEDATIVES
N/A
OTHER
PLEASE LIST ANY SERIOUS MEDICAL PROBLEMS YOU HAVE EXPERIENCED
*
NOW OR IN THE PAST HAVE YOU HAD
*
ABNORMAL BLEEDING
CHICKEN POX
ENDOCRINE/GROWTH DISORDER
HEPATITIS
LIVER PROBLEMS
HANDICAPS/DISABILITIES
SKIN RASH
TUBERCULOSIS
ANEMIA
EPILEPSY
CANCER
HIV/AIDS
LUPUS
HEMOPHILIA/BLOOD DISORDER
ARTIFICIAL BONES/JOINTS
HEARING IMPAIRMENT
HEART MURMUR
HIVES
MEASLES
DIABETES
KIDNEY PROBLEMS
ASTHMA
CHRONIC SINUS PROBLEMS
CONGENITAL HEART DEFECT
HOSPITAL STAYS
MITRAL VALVE PROLAPSE
MONONUCLEOSIS
TROUBLE SLEEPING/SLEEP APNEA
NONE
EMERGENCY CONTACT
*
RELATIONSHIP
*
PHONE NUMBER
Please enter a valid phone number.
PATIENT SURVEY
WHY ARE YOU SEEKING ORTHODONTIC TREATMENT?
*
WHO WERE YOU REFERRED BY?
*
HOW DID YOU LEARN ABOUT US?
*
PLEASE TELL US HOW IMPORTANT THE FOLLOWING ARE TO YOU
*
NOT
SOMEWHAT
IMPORTANT
VERY
EXTREMELY
LENGTH OF TREATMENT TIME
COMFORT OF TREATMENT
LATEST TECHNOLOGY
CLEAR/INVISIBLE
LOW DOWN PAYMENT
QUALITY OF TREATMENT
INTERESTED IN STARTING WITHIN THE MONTH
CHILD INFORMATION (if applicable)
PLEASE LIST THE NAME AND AGE OF ANY CHILDREN/FAMILY MEMBERS WHO MAY BE INTERESTED IN ORTHODONTIC TREATMENT IN OUR OFFICE IN THE FUTURE
PATIENT SIGNATURE
*
DATE
*
-
Month
-
Day
Year
Date
GUARDIAN SIGNATURE (if applicable)
DATE
-
Month
-
Day
Year
Date
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