Patient Information Form

Patient Information

First Name:

Last Name:

Goes By:

Address:

City:

State:

Zip:

Birthdate:

Cell Phone #:

Cell Carrier:

School (If Applicable):

Marital Status:

Single Married Divorced Widowed N/A

Minor Patient's Siblings and Ages

Name:

Age:

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Primary Referral:

Secondary Referral:

Reason for your Visit today?

Financially Responsible Information

Please select:

Parents (Minor Patients only) Self (Adult Patients) Spouse (Adult Patients)

If self and has the same address as above please check this.

Name:

Marital Status:

Single Married Divorced

Address:

City:

State:

Zip:

Birthdate:

SSN:

Relationship to Patient:

Cell Phone #:

Cell Carrier:

Email:

Employer:

Position:

Business Phone #:

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Emergency Contact Information (Someone NOT at above addresses)

I GIVE PERMISSION TO DISCLOSE PROTECTED HEALTH INFORMATION TO THE FOLLOWING PERSONS:

Name:

Relationship to Patient:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

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Medical History

Is Patient in Good General Health?

Yes No

If no, explain:

Height:

Weight:

Has patient ever been hospitalized?

Yes No

If yes, explain:

Does the Patient currently smoke?

Yes No

Have tonsils and/or adenoids been removed?

Yes No

List any medications being taken now, Give reasons:

Is the patient (Female) pregnant?

Yes No

Does patient wear contact lenses?

Yes No

List any allergies or drug sensitivities:

Has patient ever been diagnosed or treated for:

Cold Sores

Yes No

Endocrine Problems

Yes No

Heart Trouble

Yes No

Heart Murmur

Yes No

Rheumatic Fever

Yes No

Fainting or Dizziness

Yes No

Prolonged Bleeding

Yes No

Nervous Disorders

Yes No

Pneumonia

Yes No

Tuberculosis

Yes No

Bone Disorder

Yes No

Growth Disorder

Yes No

Asthma

Yes No

Anemia

Yes No

Diabetes

Yes No

Seizures/Epilepsy

Yes No

HIV/AIDS

Yes No

Hepatitis

Yes No

Liver Problems

Yes No

Radiation/Chemo

Yes No

Glaucoma

Yes No

Other Medical Conditions:

Dental History

Patient's Dentist:

Date of last cleaning or exam:

Does patient see dentist every six months:

Yes No

If the patient will be in orthodontic therapy, We require a general dental visit every six months.

Describe any injuries to the face, mouth or teeth:

Has the patient ever sucked a thumb or finger?

Yes No

Does the patient have any speech problems?

Yes No

Is there any difficult chewing or swallowing?

Yes No

Does the patient snore or have mouthbreathing?

Yes No

Has the patient been diagnosed with sleep apnea?

Yes No

Does the patient have missing or extra teeth?

Yes No

Has an orthodontist been consulted previously?

Yes No

Has a family member ever had orthodontic therapy?

Yes No

Has another family member been treated in this practice?

Yes No

If who:

Relationship to patient:

Oral Habits:

Does the patient complain of jaw joint pain or popping?

Yes No

If yes, describe the problem:

Any oral habits (Grinding teeth, Nail biting, ETC.)?

Yes No

Does the patient like His/Her smile?

Yes No

List any musical instruments played:

List any sports played: