Minor Patient Information
Whom may we thank for referring you to our office?
Today's Date
Patient's Name
Nickname
Age
Address
City
State
Zipcode
How Long At this address
Home Phone
Cell Phone
email
School
Grade
Birthdate
Sex
Height
Weight
Responsible Party
Parent Marital Status
Father's Information
Father's Name/Legal Guardian
Home Phone
cell phone
Address
City
State
Zipcode
Father's Employer
Occupation
How long at employer?
Business Address
City
State
Zipcode
Work Phone
Driver's License #
SSN
Birthdate
Mother's Information
Mother's Name/Legal Guardian
Home Phone
cell phone
Address
City
State
Zipcode
Father's Employer
Occupation
How long at employer?
Business Address
City
State
Zipcode
Work Phone
Driver's License #
SSN
Birthdate
Insurance Information
Insured's Name
Insurance Company
Group Number
Insurance Company Address
Phone Number
Is Policy Conncected With Your Union?
no
yes
Name of Union
Does the patient have dual coverage?
If yes, please complete the following secondary insruance info:
no
yes
Insured's Name
Insurance Company
Group Number
Insurance Company Address
Phone Number
Is Policy Conncected With Your Union?
no
yes
Name of Union
General Information
Number of Children in the family
Name any family member in treatment or previously with us
Name of Previous Orthodontist
General Dentist's Name
Address
Phone
Date of last Dental checkup
Currently under treatment?
no
yes
Physician's Name
Address
Phone
Date of last checkup
Currently under treatment?
no
yes
Any History Of:
Thumb or finger sucking?
no
yes
if YES, until what age?
Grinding of Teeth?
no
yes
if YES, when?
Frequent headaches or jaw pain?
no
yes
Difficulty eating any foods?
no
yes
Speech difficulty or speech therapy?
no
yes
What are the patient's hobbies?
In your own words describe the patient's main orthodontic problem
Medical History
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Is the patient in general good health at this time?
no
yes
Is the patient under any medical treatment now?
no
yes
Is the patient taking any drugs or medications?
no
yes
Has the patient ever had any adverse response to any drugs, including penicillin?
no
yes
Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.?
no
yes
Is the patient allergic to latex?
no
yes
Has the patient ever had any major operations including hip/joint replacement? If YES please specify:
no
yes
Has any wounds healed slowly or presented other complications?
no
yes
Has the patient ever had any radiation therapy or chemotherapy?
no
yes
Has the patient ever had a serious accident involving head injuries?
no
yes
Has the patient had a history of any of the following?
ASTHMA
no
yes
CARDIOVASCULAR DISEASE
no
yes
CANCER
no
yes
HAY FEVER
no
yes
HEART MURMUR
no
yes
HERPES
no
yes
SINUS PROBLEMS
no
yes
RHEUMATIC FEVER
no
yes
TUMOR OR GROWTH
no
yes
RESPIRATORY PROBLEMS
no
yes
BLOOD DISEASE
no
yes
SEXUALLY TRANSMITTED DISEASE
no
yes
TONSILLITIS
no
yes
BONE DISORDER
no
yes
EMOTIONAL PROBLEMS
no
yes
DIZZINESS
no
yes
AIDS OR HIV POSITIVE
no
yes
EXCESSIVE BLEEDING
no
yes
CONVULSIONS
no
yes
IMMUNE SYSTEM PROBLEMS
no
yes
FAINTING
no
yes
EPILEPSY
no
yes
INFECTIOUS DISEASE
no
yes
HEPATITIS OR LIVER DISEASE
no
yes
DIABETES
no
yes
ARTHRITIS OR PAINFUL JOINTS
no
yes
ALCOHOLISM
no
yes
HEARING DISORDER
no
yes
MIGRAINE HEADACHES
no
yes
DRUG ABUSE
no
yes
Other Conditions not listed
Does the patient snore?
no
yes
Does the patient have unexplained awakenings from sleep?
no
yes
Does the patient stop breathing for short periods during sleep?
no
yes
Does the patient get excessively tired during the day and/or fall asleep when they should be awake?
no
yes
Is the patient on a diet at this time?
no
yes
Does the patient have a history of fainting?
no
yes
Is the patient pregnant?
no
yes
Has the patient ever smoked or used Tobacco products?
no
yes
FEMALES: Started Menstration? If so, how long ago?
no
yes
List Current Medications
List Medications The Patient is Allergic To
Dental History
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
When were the patient's last full-mouth x-rays taken?
Where?
Do the patient's gums bleed?
no
yes
Has the patient ever had gum disease, or periodontal treatment?
no
yes
Does the patient frequently get sore spots in their mouth?
no
yes
Does the patient have any dental complaints at the present time?
no
yes
Does the patient experience frequent headaches?
no
yes
Does the patient have a history of back or neck injuries? Whiplash?
no
yes
Does the patient have any clicking or popping of their jaw (TMJ)?
no
yes
Does the patient have pain in or around their ears?
no
yes
Does any part of their mouth hurt when clenched?
no
yes
Does the patient habitually clench or grind their teeth during the night or day?
no
yes
Does the patient chew on only one side of their mouth? If so, why?
no
yes
Are any parts of their mouth sore to pressure or irritants (cold, sweets, etc )? If so, where?
no
yes
Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?
no
yes
Has the patient ever taken medication for treatment of Osteoporosis?
no
yes
PATIENT MEDICAL/DENTAL HISTORY
In case of emergency, contact:
Emergency Contact Name
Phone
PURPOSE OF CONSENT (HIPAA)
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.
Signature of Patient or Guardian
Date
Doctor Signature
Date
Security Captcha
or
If printing form, please remember to bring completed form with you to your first visit.
