Personal Information

Apointment Date
First Name
Last Name
Middle Initial
Email Address
Gender
Alias
Birthdate
Age
School
Grade
College
SS #
Hobbies  Sports
Hobbies  Sports (continued)
Home Phone Number
Address LIne 1
Address Line 2
City
State
Zip Code
Whom may we Thank for referring you
Other family members seen by us
Previous or Present Dentist
Last Visit Date
Other Family Members Seen By Us With Birthdate
Name: Birthdate:

Who Is Responsible For Making Appointments?

Name
Relation
Work Phone Number
Home Phone Number


Parent Information

Who is accompanying you today?
Email Address
Name of Person Accompanying You
Relation:
Does This Person Have Legal Custody Of You? Yes     No
Parent's Marital Status Single     Widowed     Married     Divorced                  Seperated   Partnered


Mother's Information Information

Step Mother        Guardian
Name
Employer
How Long At Current Job?
Title
Work Phone Number
Home Phone Number
SS #
Birthday
 

Father's Information Information

Step Father        Guardian
Name
Employer
How Long At Current Job?
Title
Work Phone Number
Home Phone Number
SS #
Birthday

Person Responsible for Account

Person Responsible for Account
Relation
Employer
Work Number
Work Ext
Home Number
Billing Address
City 
State
Zip
Previous Address
Previous Address
City
State
Zip
SS #
Drivers Lisence #


Dental Insurance

Primary Insurance
Orthodontic Coverage? Yes     No
Insurance Co Name
Insurance Co Address
Insurance Co Address (City)
Insurance Co Address (State)
Insurance Co Address (Zip)
Insurance Co Phone
Group Plan Local or Policy
lnsured's Name
Relation
Insured Birthdate
Insured's SS #
lnsured's Employer
Employer's Address
Employer's City
Employer's State
Employer's Zip
Secondary Insurance
Orthodontic Coverage? Yes     No
Insurance Co Name
Insurance Co Address
Insurance Co Address (City)
Insurance Co Address (State)
Insurance Co Address (Zip)
Insurance Co Phone
Group Plan Local or Policy
lnsured's Name
Relation
Insured Birthdate
Insured's SS #
lnsured's Employer
Employer's Address
Employer's City
Employer's State
Employer's Zip
 


Why Are You Coming To See The Dentist?


Medical Health History

Physicians Name
Physicians Phone Number
Date of last visit
Are you currently under the care of a physician? Yes    No
Your current physical health is: Good   Fair   Poor
Are you taking any prescriptions / over the counter drugs? Yes    No
Please list each one
Have you experienced problems with previous dental work? Yes    No
Is your water fluoridated?  Yes    No
Are you taking fluoridated supplements? Yes    No
Have you ever had any pain / tenderness in your jaw joint (TMJ / TMD)? Yes     No
Do you brush your teeth daily? Yes     No
Floss your teeth daily? Yes     No
Do your gums bleed? Yes     No
Do you require antibiotics before dental work? Yes     No
Have you ever taken Phen-Fen?
Also known as Redux or Pondimin. If so, when?		 Yes     No
For Women:
Are you using a prescribed method of birth control?
Yes    No
Are you pregnant? Yes    No
(If Yes) Week #
Are you nursing? Yes    No

For Orthodontic Treatment Please Complete The Following:

What are the main concerns that you would like orthodontics to accomplish?
Have you ever been evaluated/had orthodontic teratment before? Yes     No
Have there been any injuries to your face, 
mouth, teeth or chin?		 Yes     No
Have adenoids or tonsils been removed? Yes     No
Have you been informed of any missing or 
extra permanent teeth? 		 Yes     No
Do you still have your wisdom teeth? Yes     No
Have you played any musical instruments?
If so, what?		 Yes     No


Have you ever had any of the following disease or medical problems?

Anemia Yes     No
Any Hospital Stays Yes     No
Artificial Banes / Joints / Valves Yes     No
Abnormal Bleeding? 
Yes     No
Asthma              Yes     No
Chicken Pox
Yes     No
Cancer / Chemotherapy
Yes     No
Congenital Heart Defect  
Yes     No
Convulsions / Epilepsy Yes     No
Diabetes  
Yes     No
Handicaps / Disabilities
Yes     No
Hearing Impairment  
Yes     No
Heart Murmur 
Yes     No
Hemophilia  
Yes     No
Hepatitis
Yes     No
Hives     
Yes     No
HIV+/AIDS 
Yes     No
Kidney Problems
Yes     No
Liver Problems Yes     No
Lupus Yes     No
Measles Yes     No
Mononucleosis Yes     No
Mitra! Valve Prolapse Yes     No
Rheumatic / Scarlet Fever Yes     No
Skin Rash Yes     No
Tuberculosis (TB) Yes     No
 
Please list any serious medical condition(s) that you have ever had:
Would You Like To Discuss Anything With The Doctor In Private? Yes     No
Are you allergic to any of the following?
Asprin  
Yes     No
 Erythromycin
Yes     No
Codeine  
Yes     No
 Jewelry / Metals      
Yes     No
Dental Anesthetics 
Yes     No
 Latex
Yes     No
Penicillin  
Yes     No
 Tetracycline
Yes     No
Other    Yes     No Plastic Yes     No
Please Specify Other Allergy:


Dental History

Did/Do You Experience Any Of The Following?
Nursing Bottle Habits Yes     No
Speech Problems  Yes     No
Thumb / Finger Sucking Yes     No
Tongue Thrust Yes     No
Clenching / Grinding Teeth Yes     No
Lip Sucking / Biting  Yes     No
Mouth Breather  Yes     No
Nail Biting  Yes     No
Were you breastfed? Yes     No
Used Pacifier  Yes     No
Are your Immunizations current? Yes     No

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