Health History
Todays Date
/
Month
/
Day
Year
Date
Email Address
example@example.com
Name
Prefix
First Name
Middle Name
Last Name
I prefer to be called:
Sex
Male
Female
Birthdate
-
Month
-
Day
Year
Date
Age
Social Security #
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Status
Single
Married
Divorced
Widowed
Separated
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Employer
Employer's Address
How long there?
Occupation
When and where are the best times to reach you?
Whom may we Thank for referring you?
Other family members by us:
General Dentist
Last Visit Date
Spouse Information
Name
Employer
Birthdate
-
Month
-
Day
Year
Date
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Person responsible for account
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relation
Social Security #
Employer
Driver's License #
Orthodontic Insurance
Orthodontic Coverage
Yes
No
Dental Coverage
Yes
No
Insurance Co. Name
Insurance Co. Address
Insurance Co. Phone Number
Insured's birthdate
-
Month
-
Day
Year
Date
Insured's ID
Insured's Name
Group Number
Relation
Insured's Employer
Secondary
Orthodontic Coverage
Yes
No
Dental Coverage
Yes
No
Insurance Co. Name
Insurance Co. Address
Insurance Co. Phone Number
Insured's birthdate
-
Month
-
Day
Year
Date
Insured's ID
Insured's Name
Group Number
Relation
Insured's Employer
In the event of an emergency, is there someone who lives near you that we should contact?
Name
Relation
Work Number
Please enter a valid phone number.
Format: (000) 000-0000.
Home Number
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
SPOUSE INFORMATION
Do you have a personal physician?
Yes
No
Physicians Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Date of Last Visit
Your current physical health is:
Good
Fair
Poor
Are you currently under the care of physician?
Yes
No
Please Explain
Are you taking any prescription/over-the counter drugs?
Yes
No
Please List each one
Please List All Allergies
Any Hospital stays? Please explain:
Have you ever had any of the following diseases or medical problems?
Rows
Yes
No
Abnormal Bleeding
Anemia
Artificial Bones / Joints / Valves
Asthma / Arthritis
Blood Transfusion
Cancer / Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug/Alchohol Abuse
Emphysema
Epilepsy / Seizures / Fainting
Fever Blisters/Herpes
Glaucoma
Heart Attack / Stroke
Heart Murmur
Heart Surgery/Pacemaker
Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+/AIDS
Hospitalized for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Severe/Frequent Headaches
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Tuberculosis (TB)
Ulcers / Colitis
Venereal Disease
WOMEN: Are you pregnant?
Yes
No
You must inform us if you become pregnant
Initials
DENTAL HISTORY
What are the main concerns that you would like orthodontic treatment to accomplish?
Have you ever had or been evaluated for orthodontic treatment?
Yes
No
Have you ever had a serious/ difficult problem associated with any previous dental treatment?
Yes
No
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you like your smile?
Yes
No
Gums ever bleed?
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you generally breathe through your mouth?
Yes
No
If yes, please circle:
While Awake?
While Asleep?
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever taken Fosamax, or any other bisphosphonate?
Yes
No
Have you ever taken Phen-Fen?
Yes
No
Do you smoke or use tobacco in any form?
Yes
No
Do you have any speech problems?
I understand that the information I have given is correct to the best of my knowledge. I also understand that ti is my responsibility to inform this office of any changes in my medical status at every appointment. I authorize the dental staff to perform any necessary dental services that I may need for diagnosis and/or treatment.
Date
/
Month
/
Day
Year
Date
We permit this office to verify the credit status of patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services
Date
/
Month
/
Day
Year
Date
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Date
/
Month
/
Day
Year
Date
Submit
Should be Empty: