Health History Form
ENTER YOUR NAME
*
First Name
Last Name
PREFERRED NAME
DOB
*
-
Month
-
Day
Year
Date
GENDER
*
REFERRED BY
PAST/PRESENT FAMILY IN TREATMENT AT OUR OFFICE?
PLEASE LIST NAMES
HOW DID YOU LEARN ABOUT US?
*
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
DENTAL & MEDICAL INFORMATION
DENTIST
PHYSICIAN NAME
Approximate date of last dental cleaning?
PLEASE INDICATE IF YOU HAVE (PLEASE CHECK ALL THAT APPLY)
PREVIOUS ORTHODONTIC EXAM
PREVIOUS 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
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
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.
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 IMMEDIATELY
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 / Responsible Party Signature:
*
DATE
*
-
Month
-
Day
Year
Date
GUARDIAN SIGNATURE (if applicable)
DATE
-
Month
-
Day
Year
Date
Submit
Should be Empty: