Patient Information/Health History Form

  • Patient Information/Health History Form

  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Has the patient been examined by an orthodontist before?*
  • If the patient is a child, are they adopted?
  • Date of Last Cleaning*
     - -

  • Guardian #1/Insurance Information

  • *
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Orthodontic Insurance (If Applicable)

  • Format: (000) 000-0000.
  • Is there a second guardian and/or additional insurance to add?*

  • Guardian #2/Insurance Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
     - -
  • Format: (000) 000-0000.

  • Orthodontic Insurance (If Applicable)

  • Format: (000) 000-0000.

  • Sleep/Airway Issue

  • Does the patient tend to be a mouthbreather?*
  • Has the patient seen an Ear, Nose & Throat Specialist?*
  • Does the patient snore at night?*
  • Is the patient often sleepy during the day?*
  • Is the patient using a sleep apnea device?*

  • Dental/Medical History

  • Rows
  • Do your gums bleed when you brush?*
  • Is the patient seeing any other dental specialists (ex: Periodontist)?*
  • Any dental restorations needing to be completed?*
  • Have there ever been any injuries to the face, mouth, or chin?*
  • Have you ever lost or chipped any teeth?*
  • Do you have any pain or soreness around your face, neck or back?*
  • Is any part of your mouth sensitive to temperature or pressure?*
  • Is the patient currently pregnant?*
  • If Yes, when is the due date?*
     - -
  • Have the adenoids been removed?*
  • Have the tonsils been removed?*
  • Currently taking any medications?*
  • Are antibiotics necessary prior to treatment?*
  • Allergies?*
  • Any diseases or problems not mentioned above?*
  • Please check if the patient has, or ever had, any of the following habits?*

  • Signed Consent

  • I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

    I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine the appropriate orthodontic treatment on the above-named patient.

    I also authorize this office to leave messages about appointments on my voicemail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

  • Date*
     - -
  • Should be Empty: