Patient Health History Form

First Name

Middle

Last Name

I prefer to be called

Birthdate

Street Address

City

State

Zip

Home Phone No.

Work Phone No.

Cell Phone No.

Email address

Social Security Number

School

Grade

If patient is a minor, give parent's or guardian's name

Please list the names of any friends or family currently in the practice

List any sports, hobbies or musical instruments played

Whom may we thank for referring you to our office?

Responsible Party Information

Full Name

Relationship to Patient

Birthdate

Residence

Mailing Address (if different)

Previous Address (less than 3 years)

Email address

Work Phone No.

Cell Phone No.

Social Security Number

Employer

Occupation

Number of Years Employed

Spouse's Name

Relationship to Patient

Social Security Number

Employer

Number of Years Employed

Birthdate

Occupation

Email address

Work Phone No.

Cell Phone No.

Dental Insurance Information

Policy Holder's Name

Relationship to Patient

Policy Holder's Employer

Insurance Company

Subscriber ID #

Group Number

Insurance Company Address

Insurance Co. Phone No.

Do you have dual coverage?

If so, please name the Insurance Company below:

Policy Holder's Name

Relationship to Patient

Policy Holder's Employer

Insurance Company

Subscriber ID #

Group No.

Insurance Company Address

Insurance Co. Phone No.

Emergency Information

Name of the nearest relative not living with you

Complete Address

Phone

Relationship to Patient

City

State

Zip

Dental History

General Dentist

Check-up Frequency

Last Dental Visit

Does the patient need to premedicate prior to dental visit?

If check, when?

What is the patient's main orthodontic concern?

If any of the above dental questions were 'checked,' please explain

Have you had a TMJ screening?

Have you been treated for TMJ?

Do you clench/grind your teeth?

Do you have difficulty chewing or opening your mouth?

Do you have a history of jaw joint problems?

Do you notice clicking or popping in your jaw joint?

Has your jaw ever locked?

Does your bite feel uncomfortable or unusual?

If any of the above TMJ questions were answered 'Check,' please explain:

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician Name

Date of Last Visit

Has there been any change in the patient's general health within the last year?

Yes No

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?

Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?

List any medications currently being taken by the patient (include non-prescription)

Allergies or drug reaction to (check those that apply)

Latex

Sulfa drugs

Local anesthetics

Latex / Metal allergy

Penicillin or other antibiotics

Aspirin, Ibuprofen, Tylenol

Codeine or other narcotics

Other

List any drug allergies or sensitivities (not listed above) that the patient may have

Are there any medical conditions we have not discussed that you feel we should be aware of not listed above?

*Female Patients Only*

Are you pregnant?

Are you anticipating getting pregnant?

Are you taking birth control pills?

Patient Motivation for Orthodontic Treatment

What do you feel are the main problems with your teeth and/or bite?

How do you feel orthodontics can help?

Permission to send automated appointment reminder text/emails and to use your/your child's photo on office website, Facebook/ Instagram page and in office

Type your name if you give permission for Schlosser Orthodontics to send automated appointment reminder text/emails

Type your name here to give permission to use the patient's photo for the office website, Facebook/Instagram page, or in the office

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.