ABOUT YOU
Today's Date:
Name:
Last Name
First Name
Title
I prefer to be called:
MALE
FEMALE
Birthdate:
Age:
SS#:
Home Address:
Street
City
State
ZIP
Marital Status:
Single
Married
Divorced
Widowed
Separated
Home Phone:
Work Phone:
E-mail address
Employer:
Employers Address:
Street
City
State
ZIP
How long there?:
Occupation:
Where and when are the best times to reach you?:
Whom may we thank for referring you?:
Other family members seen by us:
General Dentist:
Last Visit Date:
SPOUSE INFORMATION
Name:
Last Name
First Name
Title
Employer:
Work Phone:
Birthdate?:
SS#:
Person Responsible for Account:
Work Phone:
Home Phone:
Billing Address:
Street
City
State
ZIP
Relation:
SS#:
Employer:
DL#:
ORTHODONTIC INSURANCE
PRIMARY
Orthodontic Coverage:
YES
NO
Insurance Company Name?:
Insurance Company Address:
Insurance Company Phone #?:
Group Number (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS#:
Insured's Employer:
SECONDARY
Orthodontic Coverage:
YES
NO
Insurance Company Name?:
Insurance Company Address:
Insurance Company Phone #?:
Group Number (Plan, Local, or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS#:
Insured's Employer:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Work Phone:
Home Phone:
MEDICAL HISTORY
Do you have a personal physician?:
YES
NO
Physician's Name?:
Physician's Phone #:
Date of last visit:
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 drugs?:
YES
NO
Please list each one:
For Women:
Are you taking birth control pills?:
YES
NO
Are you pregnant?:
YES
NO Week#:
Are you nursing? :
YES
NO
Have you ever had any of the following diseases or medical problems?
Anemia/Radiation Treatment:
YES
NO
Artificial Bones/Joints:
YES
NO
Artificial Valves:
YES
NO
Asthma/Arthritis:
YES
NO
Blood Transfusions:
YES
NO
Cancer/Chemotherapy:
YES
NO
Congenital Heart Defect:
YES
NO
Diabetes/Tubercolosis(TB):
YES
NO
Difficulty Breathing:
YES
NO
Drug/Alcohol Abuse:
YES
NO
Emphysema/Glaucoma:
YES
NO
Epilepsy/Seizures/Fainting Spells:
YES
NO
Fever Blisters/Herpes:
YES
NO
Heart Attack/Stroke:
YES
NO
Heart Murmur:
YES
NO
Heart Surgery/Pacemaker:
YES
NO
Hemophilia/Abnormal Bleeding:
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
Rheumatic/Scarlet Fever:
YES
NO
Severe/Frequent Headaches:
YES
NO
Shingles:
YES
NO
Sinus Problems:
YES
NO
Ulcers/Colitis:
YES
NO
Veneral Disease:
YES
NO
Please list any serious medical condition(s) that you haver ever had:
Are you allergic to any of the following:
Aspirin:
YES
NO
Any Metal/Plastic:
YES
NO
Codeine:
YES
NO
Dental Anesthetics:
YES
NO
Erythromycin:
YES
NO
Latex:
YES
NO
Penicillin:
YES
NO
Tetracycline:
YES
NO
Other:
YES
NO
Please list any other drug you are allergic to:
DENTAL HISTORY
What are the 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
Do you now or have you ever experieced 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
Do your gums ever bleed?:
YES
NO
Have you ever had an injury to your:
MOUTH
TEETH
CHIN
Do you generally breath through your mouth when awake:
YES
NO
Do you generally breath through your mouth when asleep?:
YES
NO
Do you have any missing or extra permanent teeth?:
YES
NO
SIGNATURE
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 of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent.
(you will be asked to sign this document on your first visit to our office)
______________________________________________________________
signature
date
THANK YOU FOR FILLING OUT THIS FORM COMPLETELY
This office reserves the right to verify the credit status of potential 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.
(you will be asked to sign this document on your first visit to our office)
______________________________________________________________
signature
date
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.