Patient Information/Health History Form

Patient Information/Health History Form
Patient's First Name*
Patient's Last Name*
Preferred Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Interests/Sports/Hobbies
Gender*
Home Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Age
Race
Cell Phone
Please enter a valid phone number.
School/Employer
Grade/Position
Work Phone
Please enter a valid phone number.
How did you hear about our office?*
Patient's Email
example@example.com
Family Members Treated in Our Office
Reason for Consultation*
Dentist*
Date of Last Cleaning*
Has the patient been examined by an orthodontist before?*

YesNo
If the patient is a child, are they adopted?

YesNo
Date of Last Cleaning*

MonthDayYear
Date
Guardian #1/Insurance Information
SelfSpouseFatherMotherStep-ParentOther
If Other, Please Specify:*
Guardian's First Name*

First NameLast Name
First Name
Last Name
Guardian's First Name*
Guardian's Last Name*
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Work Phone
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security Number*
Cell Phone*
Please enter a valid phone number.
Guardian's Email*
example@example.com
Orthodontic Insurance (If Applicable)
Insurance Company
Phone Number
Please enter a valid phone number.
Subscriber/Member ID
Is there a second guardian and/or additional insurance to add?*

YesNo
Guardian #2/Insurance Information
SelfSpouseFatherMotherStep-ParentOther
Guardian's Name

First NameLast Name
Home Phone
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Work Phone
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Social Security Number
Cell Phone
Please enter a valid phone number.
Guardian's Email
example@example.com
Orthodontic Insurance (If Applicable)
Insurance Company
Phone Number
Please enter a valid phone number.
Subscriber/Member ID
Sleep/Airway Issue
Does the patient tend to be a mouthbreather?*

YesNo
Has the patient seen an Ear, Nose & Throat Specialist?*

YesNo
Does the patient snore at night?*

YesNo
Is the patient often sleepy during the day?*

YesNo
Is the patient using a sleep apnea device?*

YesNo
Dental/Medical History

Please check if the patient has a history of the following medical conditions:*

	Yes	No	Explain
ADD/ADHD
AIDS/HIV
Acid Reflux
Anemia
Arthritis
Asthma
Autism
Bone Disorders
Cancer
Cerebral Palsy
Chest Pain
Chronic Neck Pain
Cold Sores/Herpes
Diabetes
Down Syndrome
Ear Pain
Emotional Disorders
Endocrine Problems
Epilepsy
Headaches
Heart Conditions
Hepatitis
High Blood Pressure
Immune Problems
Jaw Clicking
Jaw Pain
Kidney Problems
Low Blood Pressure
Muscular Disorders
Nervous Disorders
Organ Transplant
Osteoporosis
Painful Chewing
Periodontal Problems
Prolonged Bleeding
Rheumatic Fever
Scoliosis
Seizures
Sinus Problems
TMJ Problems
Tuberculosis

Do your gums bleed when you brush?*

YesNo
Is the patient seeing any other dental specialists (ex: Periodontist)?*

YesNo
If Yes, please explain:*
Any dental restorations needing to be completed?*

YesNo
If Yes, what work?*
Have there ever been any injuries to the face, mouth, or chin?*

YesNo
If Yes, please explain:*
Have you ever lost or chipped any teeth?*

YesNo
If Yes, which tooth/teeth:*
Do you have any pain or soreness around your face, neck or back?*

YesNo
If Yes, please describe where:*
Is any part of your mouth sensitive to temperature or pressure?*

YesNo
If Yes, please describe:*
Is the patient currently pregnant?*

YesNo
If Yes, when is the due date?*

MonthDayYear
Date
Have the adenoids been removed?*

YesNo
If Yes, when?*
Have the tonsils been removed?*

YesNo
If Yes, when?*
Currently taking any medications?*

YesNo
If Yes, please list:*
Are antibiotics necessary prior to treatment?*

YesNo
If Yes, please list:*
Allergies?*

YesNo
If Yes, please list:*
Any diseases or problems not mentioned above?*

YesNo
If Yes, please list:*
Please check if the patient has, or ever had, any of the following habits?*

Cheek, tongue or lip bitingClenching TeethFingernail BitingGrinding TeethTongue SuckingThumb SuckingTongue ThrustingNone
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.
Signature*

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Relationship to Patient*
Date*

MonthDayYear
Date
Should be Empty:

Patient Information/Health History Form

Guardian #1/Insurance Information

Orthodontic Insurance (If Applicable)

Guardian #2/Insurance Information

Orthodontic Insurance (If Applicable)

Sleep/Airway Issue

Dental/Medical History

Signed Consent