1. About You
Today's Date
Name
I prefer to be called:
Male
Female
Birthdate:
Age:
SS#:
Home Address:
Single
Married
Widowed
Separated
Divorced
Home #:
Cell #:
Wk #:
Ext#:
DL#:
Employer:
How Long at Current Job:
Job Title:
Employer's Address:
Where & when are best time to reach you?
Whom may we Thank for referring you?
Other family members seen by us:
General Dentist:
Last Visit Date:
2. Spouse's Information
His / Her Name:
Wk #:
Ext#:
Employer:
Birthdate:
Job Title:
SS#:
DL#:
Email address:
3. Person Responsible For Account
Name:
Relation:
Billing Address:
Home #:
DL #:
Employer:
Work #:
Ext#:
SS#:
Email address:
4. Primary Orthodontic Insurance
Orthodontic Coverage?:
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone
Group # (Plan, Local, or Policy #):
Insured's Name:
Insured's Birthdate:
SS#:
Relationship to Patient:
DL#:
Insured’s Employer:
Secondary Orthodontic Insurance
Orthodontic Coverage?:
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone
Group # (Plan, Local, or Policy #):
Insured's Name:
Insured's Birthdate:
SS#:
Relationship to Patient:
DL#:
Insured’s Employer:
5. Emergency contact
His /Her Name:
Relation:
Hm #:
Wk#:
6. Medical History
Do you have a personal physician?
Yes
No
His /Her Name:
Phone number:
Your current physical health is:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Please explain:
Are you taking any prescription / over-the-counter drug?
Yes
No
Please list each one:
For Women: Are you taking birth control pills?
Yes
No
Are you pregnant
Yes
No
Have you ever had any of the following diseases or medical problems?
Please list any serious medical condition(s) that you have ever had:
Check here to select No to all the Questions
Yes
No
Abnormal Bleeding
Yes
No
Anemia
Yes
No
Artificial Bones/ Joints / Valves
Yes
No
Asthma / Arthritis
Yes
No
Cancer / Chemotherapy
Yes
No
Congenitally Heart Defect
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Heart Surgery / Pacemaker
Yes
No
Drug / Alcohol Abuse
Yes
No
Emphysema
Yes
No
Epilepsy / Seizures / Fainting
Yes
No
Fever Blisters / Herpes
Yes
No
Glaucoma
Yes
No
Heart Attack / Stroke
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
Hepatitis
Yes
No
High / Low Blood Pressure
Yes
No
HIV+ / AIDS
Yes
No
Hospitalized for Any Reason
Yes
No
Kidney Problems
Yes
No
Mitral Valve Prolapse
Yes
No
Psychiatric Problems
Yes
No
Radiation Treatment
Yes
No
Severe / Frequent Headaches
Yes
No
Sickle Cell Disease / Traits
Yes
No
Sinus Problems
Yes
No
Tuberculosis (TB)
Yes
No
Ulcers / Colitis
Are you allergic to any of the following?
Yes
No
Aspirin
Yes
No
Any Metals/Plastics
Yes
No
Dental Anesthetics
Yes
No
Erythromycin
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Other
Please list any other drugs/materials that you are allergic to:
7. Tell Us Your Concerns
What are your main concerns that you would like orthodontics 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 work?
Yes
No
Have there been any injuries to the face, mouth, teeth, or chin?
Yes
No
Do you have any missing or extra permanent teeth?
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
Do you have any speech problems?
Do you generally breathe through your mouth?
If yes, please circle:
While Awake?
While Asleep?
Do you have clenching / grinding teeth habit?
Yes
No
Have you ever taken Phen-Fen?(Also known as Redux or Pondimin)If yes, when?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Signature
Date
This office reserves the right 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.
Signature
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.
Signature
Date
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
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