Patient Information Form

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– Step 1 of 4

Patient Name

Preferred Name

Gender

Date of Birth

Age

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Patient Home Phone

Patient Work Phone

Patient Cell Phone

Patient E-mail

School / Occupation

Sports / Hobbies

Family Dentist

Dentist Phone

Physician

Physician Phone

Who may we thank for referring you?

Have we seen other family members?

• Yes
• No

Who

Names/ages of siblings or children

Have you seen another Orthodontist?

• Yes
• No

Who

The reason you seek orthodontic treatment

If patient is a child:

• Yes
• No

Mother's Name

Father's Name

Parents Marital Status is:

• Married
• Divorced
• Separated

Child Lives with:

Next

Names of financially responsible parties or legal guardians

Primary

Name

Relation to patient

Address (copy)

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Home Phone

Work Phone

Mobile Phone

Email

Date of Birth

Social Security#

Employer

Occupation

Dental Insurance

Insurance ID#

Insurance Phone

Secondary

Name

Relation to patient

Address

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Home Phone

Work Phone

Mobile Phone

Email

Date of Birth

Social Security#

Employer

Occupation

Dental Insurance

Insurance ID#

Insurance Phone

Next

MEDICAL HISTORY

General Health

• Excellent
• Good
• Fair
• Poor

Height

Weight

Birth Defects

Do you have a Latex allergy?

• Yes
• No

Allergic to what medications?

Presently under medical care for

Drugs or medications being taken now (drug & dosage)

Other medical information we should be aware of:

* Is premedication required for dental visits?

• Yes
• No

Which antibiotic do you take?

Please answer Yes or No to the following and indicate the date:

Adopted Child

• Yes
• No

Date

AIDS

• Yes
• No

Date

Allergies

• Yes
• No

Date

Blood/Bleeding Problems

• Yes
• No

Date

Breathing Heart Difficulties

• Yes
• No

Date

Bone Disorder

• Yes
• No

Date

Cerebral Palsy

• Yes
• No

Date

Diabetes

• Yes
• No

Date

Ear/Nose Infections

• Yes
• No

Date

Emotional

• Yes
• No

Date

Endocrine Disorder

• Yes
• No

Date

Epilepsy

• Yes
• No

Date

Eye Disorders

• Yes
• No

Date

Fainting Spells

• Yes
• No

Date

Heart Disorder/Murmur

• Yes
• No

Date

Hearing Difficulties

• Yes
• No

Date

Hepatitis

• Yes
• No

Date

Hospitalized

• Yes
• No

Date

Hyperactivity

• Yes
• No

Date

Learning Disorder

• Yes
• No

Date

Liver Disorder

• Yes
• No

Date

Rheumatic Fever

• Yes
• No

Date

Scoliosis

• Yes
• No

Date

Seizures/Convulsions

• Yes
• No

Date

Speech Difficulty

• Yes
• No

Date

Tonsils (removed)

• Yes
• No

Date

Tuberculosis

• Yes
• No

Date

STD

• Yes
• No

Date

Other

Next

DENTAL HISTORY

Date of last dental checkup

Injury to the face or teeth?

Jaw joint (TMJ problems)

• Noise
• Pain
• Earaches/Headaches
• Soreness/Stiffness

Other dental information we should be aware of

Other Habits (thumb, nail biting, etc.)

Breathing

• Nose
• Mouth
• Difficulty at night
• Snoring

Mouth

• Usually open
• Frequently open
• Seldom open

Please answer Yes or No to the following due to a poor bite and indicate the date:

Worn or sore teeth

• Yes
• No

Date

Loose teeth

• Yes
• No

Date

Bone/gum recession

• Yes
• No

Date

Headaches

• Yes
• No

Date

Jaw / Joint problems

• Yes
• No

Date

Bruxism/clenching

• Yes
• No

Date

Limited opening

• Yes
• No

Date

Difficulty chewing

• Yes
• No

Date

Speech difficulty

• Yes
• No

Date

The information contained in this health history is true and correct to the best of my knowledge and I will advised the office of any changes in health status of the patient prior to any orthodontic visits.

Signature of person who filled out health history

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