Suzanne Grey - Grey Orthodontics

Submit Your Health History Form Online to Your Dentist

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You may need to provide a signature at the office to verify that the information you submitted online is accurate.
Patient Information

Items marked with asterisk (*) must be completed.
First Name*
Middle Name
Last Name*
I prefer to be called (Nickname)
Address
Street
City
State/Province
Zip/Postal Code
Country
Home Phone*
Cell/Other Phone
Work Phone
Email Address*
example@example.com
Gender*

MaleFemale
Birthdate (MM-DD-YYYY)*

MonthDayYear
Date
Whom may we thank for referring you to our office?*
If patient is a minor, give parent's or guardian's name
Other family members seen by us
Responsible Party Information
Full Name
Residence
Street
City
State/Province
Zip/Postal Code
Country
Home Phone
Mailing Address (If different)
Street
City
State/Province
Zip/Postal Code
Country
Home Phone
Cell/Other Phone
If patient is under 18, please complete this section.
Email Address
example@example.com
Birthdate

MonthDayYear
Date
Previous Address
Street
City
State/Province
Zip/Postal Code
Country
If less than 3 years
Relationship to Patient
Employer
Occupation
Number of Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
Number of Years Employed
Birthdate

MonthDayYear
Date
Home Phone
Work Phone
Cell/Other Phone
Email Address
example@example.com
Emergency Information
Name of the nearest relative not living with you
Phone
Complete Address
Street
City
State/Province
Zip/Postal Code
Country
Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician
Date of Last Visit
Phone
Address
Street
City
State/Province
Zip/Postal Code
Country
Please check any of the following which apply to you, and add any relevant comments.
Are you taking any medication?
Comment:
Are you taking any medication?
Comment:
Do you have a history of any major illness?
Comment:
Have you had any major operations?
Comment:
Have you ever been involved in a serious accident?
Comment:
Please check any of the following that you have had or currently have:
Abnormal bleeding/HemophiliaArthritisBone DisordersDiabetesEpilepsyHeart ProblemsHepatitis/Liver ProblemsHigh Blood PressureKidney ProblemsNervous DisordersRadiation/ChemotherapyTuberculosis
AnemiaAsthma or Hay feverCongenital Heart DefectDizzinessGastrointestinal DisordersHeart MurmurHerpesHIV/AidsPneumoniaProlonged BleedingRheumatic FeverTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
Dental History
General Dentist
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?
Please check any of the following which apply to you, and add any relevant comments.
Are you presently in any dental pain?
Comment:
Have you ever experienced any unfavorable reaction to dentistry?
Comment:
Have you ever lost or chipped any teeth?
Comment:
Have there been any injuries to face, mouth or teeth?
Comment:
Is any part of your mouth sensitive to temperature?
Comment:
Is any part of your mouth sensitive to pressure?
Comment:
Do you have any type of thumb or tongue habit?
Comment:
Are you a mouth breather?
Comment:
Have you ever seen a dentist?
If yes, who and when?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Comment:
Are you aware of your jaws clicking or popping?
Comment:
Are you aware of clenching your teeth during the day?
Comment:
Have you ever been told that you grind your teeth?
Comment:
Do you have 'tension' headaches?
Comment:
Have you ever experienced chronic ringing in your ears?
Comment:
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.
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Submit Your Health History Form Online to Your Dentist

Patient Information

Address

Responsible Party Information

Residence

Mailing Address (If different)

Previous Address

Emergency Information

Complete Address

Medical History

Address

Dental History