PATIENT INFORMATION
Patients Name
Last
First
Middle
Nickname
Gender
Male
Female
Address
Street
City
State
Zip
Home Phone
Birth date
Age
S.S.N.
How did you hear of our office?
RESPONSIBLE PARTY INFORMATION
Name
Marital Status
Last
First
Middle
Residence
Street
City
State
Zip
Mailing Address
Street
City
State
Zip
How long at this address
Home Phone
Work Phone
Previous Address
(if less than 3 years )
Street
City
State
Zip
Social Security #
Birth date
Relationship to Patient
Employer
Occupation
Number Years Employed
Spouse's Name
Relationship to Patient
Last
First
Middle
Employer
Occupation
Number Years Employed
Social Security #
Birth Date
Work Phone
INSURANCE INFORMATION
Insured's Name
Insured's Social Security #
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Insurance Phone Number
Do you have dual coverage?
Yes
No
Insured's Name
Insured's Social security #
Insured's Employer
Insurance Company
Group Number
Local Number
Insurance Company Address
Insurance Company Phone Number
Insured's Employer
Medical History
Family Physician
Phone Number
Date of Last Visit
YES
NO
YES
NO
Are you taking any medication ?
Have you had any major operations ?
Are you allergic to any medications ?
Have you ever been involved in a serious accident ?
Do you have a history of a major illness ?
Have you ever had any of the following diseases or medical problems
YES
NO
YES
NO
Abnormal Bleeding / Hemophilia
Hepatitis / Liver Problems
Anemia
Herpes
Arthritis
High Blood Pressure
Asthma or Hayfever
HIV + / AIDS
Bone Disorders
Kidney Problems
Congenital Heart Defect
Nervous Disorders
Diabetes
Pneumoia
Dizziness
Prolonged Bleeding
Epilepsy
Radiation / Chemotherapy
Gastrointestinal Disorders
Rheumatic Fever
Heart Problems
Tuberculosis
Heart Murmur
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
PATIENT DENTAL HISTORY
General Dentist
Date of Last Visit
Dentist Phone Number
What Concerns you most about your teeth ?
YES
NO
Are you presently in any dental pain
Have you ever experienced any unfavorable reaction to dentistry ?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth or teeth?
Is any part of your mouth sensitive to temperature or pressure ?
Do your gums bleed when you brush ?
Do you have any type of thumb or tongue habit ?
Are you a mouth breather
Have you ever seen an orthodontist ?
Has anyone in the family received orthodontic treatment ?
How did they feel about the result ?
What is your attitude toward orthodontic treatment ?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping ?
Are you aware of clenching your teeth during the day ?
Have you ever been told that you grind your teeth ?
Do you have "tension" headaches ?
Have you ever experienced chronic ringing in your ears ?
Are you aware some appointments will be during school / work hours ?