jupiterorthodontics.com - Health History Form

Health History
Confidential Patient Information
Name:*

First NameMiddle NameLast Name
Nickname:
Birthdate:*

MonthDayYear
Date
Gender:*

MaleFemaleOther
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Phone:*
Please enter a valid phone number.
2nd/Cell Phone:
Please enter a valid phone number.
Email:
example@example.com
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Confidential Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Name*

First NameMiddle NameLast Name
Marital Status:
Relationship to Patient:
Birthdate:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com
Main Phone:*
Please enter a valid phone number.
2nd/Cell Phone:
Please enter a valid phone number.
Work Phone #:
Please enter a valid phone number.
Social Security #:
Employer:
Occupation:
Spouse or Other Parent's Name:

First NameMiddle NameLast Name
Relationship to Patient:
Social Security #:
Birthdate:

MonthDayYear
Date
Employer:
Occupation:
Work Phone #:
Please enter a valid phone number.
Dental Insurance Information
Orthodontic Coverage?*

YesNo
Policy Holder's Name:
Policy Holder's DOB:

MonthDayYear
Date
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone No.:
Please enter a valid phone number.
Do you have dual dental coverage?

YesNo
If yes, complete information below
Policy Holder's Name:
Policy Holder's DOB:

MonthDayYear
Date
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone No.:
Please enter a valid phone number.
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone Number:
Please enter a valid phone number.
Relationship to Patient:
Dental History
Current Dentist?*

YesNo
Dentist Name:
Last Dental Visit:*

MonthDayYear
Date
Last Dental Cleaning:*

MonthDayYear
Date
Has the patient had an orthodontic consult or treatment?

YesNo
If so, when?
Does the Patient need to premedicate prior to dental visit?

YesNo
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?

YesNo
Clench or Grind Teeth?

YesNo
Oral habits (thumb/finger sucking, lip/nail biting)?

YesNo
Injury to face, jaw, teeth or mouth?

YesNo
Previous periodontal (gum) treatment?

YesNo
Abnormal swallowing (tongue thrust)?

YesNo
Brush teeth daily?

YesNo
Floss teeth daily?

YesNo
Mouth breathing?

YesNo
Snores during sleep?

YesNo
Any missing or extra permanent teeth?

YesNo
Apprehensive about dental care?

YesNo
Thumb or finger habit as a child?

YesNo
Jaw Fractures, cysts, mouth infections?

YesNo
Problems with food trapped between teeth?

YesNo
Is all dental work completed at this time?

YesNo
If any of the above dental questions were answered 'Yes', please explain:
Have you been treated for "TMJ"?

YesNo
Do you notice clicking or popping in your jaw joint?

YesNo
Do you clench your teeth?

YesNo
Has your jaw ever locked?

YesNo
Do you have difficulty chewing or opening your mouth?

YesNo
Do you experience any facial pain?

YesNo
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Physician Phone Number:
Please enter a valid phone number.
Has the patient had a any hospitalization?*

YesNo
If so, what for?
Take Bisphosphonates (Fosamax, Boniva)*

YesNo
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex / Metal Allergy*

YesNo
List any drug allergies or sensitivities (not listed above) that the patient may have:
Does the patient have any medical conditions?*

YesNo
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Problems*

YesNo
Liver Problems / Jaundice / Hepatitis*

YesNo
Kidney Problems*

YesNo
Hypertension/High Blood Pressure/Low Blood Pressure*

YesNo
Anemia / Blood disorder*

YesNo
HIV/AIDS*

YesNo
Tonsils/Adenoids Removed*

YesNo
Physical Disabilities*

YesNo
Arthritis / Joint problems*

YesNo
Sinus trouble*

YesNo
Bed wetting*

YesNo
Substance abuse problem (past or present)*

YesNo
Prosthetic joints*

YesNo
Diabetes*

YesNo
Growth Problems*

YesNo
Tuberculosis or Lung Problems*

YesNo
Pneumonia*

YesNo
Cancer*

YesNo
Received Radiation Treatment*

YesNo
Thyroid / Endocrine Problems*

YesNo
Gastrointestinal Disorders*

YesNo
Hormone Therapy*

YesNo
Nervous Disorders*

YesNo
Bone Disorders/Osteoporosis*

YesNo
Seizures / Epilepsy / Neurological Problems*

YesNo
Asthma*

YesNo
Respiratory problems / Emphysema*

YesNo
FEMALES: Are you pregnant*

YesNo
If any of the above medical questions were answered 'Yes', please explain:
Sensory Disorder*

YesNo
Autism Spectrum Disorder*

YesNo
Attention Deficit Hyperactivity Disorder*

YesNo
Patient Motivation for Orthodontic Treatment
Straighten Front Teeth

UpperLowerBoth
Straighten Back Teeth

UpperLowerBoth
Move Upper Teeth

ForwardBackward
Move Lower Teeth

ForwardBackward
Eliminate Spaces Between Teeth

UpperLowerBoth
Eliminate Crowding of Teeth

UpperLowerBoth
Make Line of Upper Teeth More Level
Other
Patients Under 18

If patient is under the age of 18, please answer the following questions:
School:
Grade:
Has patient begun puberty:

YesNo
If patient is a girl, has menstruation begun:

YesNo
If patient is a boy, has their voice changed or have facial hair:

YesNo
Has either biological parent ever had orthodontic treatment:
Should be Empty:

Health History

Confidential Patient Information

Confidential Responsible Party Information

Dental Insurance Information

Emergency Information

Dental History

Medical History

Patient Motivation for Orthodontic Treatment

Patients Under 18