Dental Forms New Patient FormMedical Dental History Form for Adult PatientsMedical Dental History Form for Patients Under Age 18Confidential Questionnaire FormNew Patient Form Please prove you are human by selecting the House. Medical Dental History Form for Adult Patients PATIENTDate Name First Last I prefer to be calledBirth date Sex Male Female Social Insurance NumberMarital Status Single Married Separated Divorced Widowed Home addressCity, State, Zip codeHome PhoneCell PhoneWork PhoneEmail OccupationEmployerCLOSEST RELATIVESpouse or closest relative’s name(s)Relationship to patientAddress (if different than patient address)Home PhoneCell PhoneWork PhoneDENTISTPatient’s DentistAddress, City, StateLast seenReasonNext AppointmentOther dentists/dental specialists now being seen:City, StateReasonPHYSICIANPatient’s PhysicianCity, StateLast seenReasonNext AppointmentMost recent physical examOther physicians/health care providers being seen now:NameCity, StateReasonNameCity, StateReasonGENERAL INFORMATIONWhat concerns you about your teeth?Who suggested that you might need orthodontic treatment?Why did you select our office?Have you had any previous orthodontic treatment? Please describeHave any other family members been treated in this office? Please name them.Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.FINANCIAL RESPONSIBILITYWho is financially responsible for this account?AddressCity, State, ZipHome PhoneCell PhoneWork PhoneSocial Security NumberEmployerWho will be responsible for bringing the patient to orthodontic appointments?DENTAL INSURANCEPrimary policy holder’s full nameBirth Date Social Security NumberRelationship to patientAddress and phone (if not listed above)EmployerAddressInsurance companyGroup NumberID NumberDoes this policy have orthodontic benefits? Yes No Don't know Seondary policy holder’s full nameBirth Date Social Security NumberRelationship to patientAddress and phone (if not listed above)EmployerAddressInsurance companyGroup NumberID NumberDoes this policy have orthodontic benefits? Yes No Don't know MEDICAL INSURANCEPolicy holder’s full nameInsurance companyYour answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).MEDICAL HISTORYNow or in the past, have you had Birth defects or hereditary problems? Yes No Don't know Bone fractures, or major injuries? Yes No Don't know Any injuries to face, head, neck? Yes No Don't know Arthritis or joint problems? Yes No Don't know Endocrine or thyroid problems? Yes No Don't know Diabetes or low sugar? Yes No Don't know Kidney problems? Yes No Don't know Cancer, tumor, radiation treatment or chemotherapy? Yes No Don't know Stomach ulcer, hyperacidity, acid reflux? Yes No Don't know Immune system problems? Yes No Don't know History of osteoporosis? Yes No Don't know Gonorrhea, syphilis, herpes, sexually transmitted diseases? Yes No Don't know AIDS or HIV positive? Yes No Don't know Hepatitis, jaundice or other liver problem? Yes No Don't know Polio, mononucleosis, tuberculosis, pneumonia? Yes No Don't know Seizures, fainting spells, neurologic problem? Yes No Don't know Mental health disturbance or depression? Yes No Don't know Vision, hearing, or speech problems? Yes No Don't know History of eating disorder (anorexia, bulimia)? Yes No Don't know High or low blood pressure? Yes No Don't know Excessive bleeding or bruising, anemia? Yes No Don't know Chest pain, shortness of breath, tire easily, swollen ankles? Yes No Don't know Heart defects, heart murmur, rheumatic heart disease? Yes No Don't know Angina, arteriosclerosis, stroke or heart attack? Yes No Don't know Skin disorder (other than common acne)? Yes No Don't know Do you eat a well-balanced diet? Yes No Don't know Frequent headaches or migraines? Yes No Don't know Frequent ear infections, colds, throat infections? Yes No Don't know Asthma, sinus problems, hayfever? Yes No Don't know Tonsil r adenoid condition? Yes No Don't know Do you frequently breathe through your mouth? Yes No Don't know DENTAL HISTORYNow or in the past, have you had Permanent or extra (supernumerary) teeth removed? Yes No Don't know Supernumerary (extra) or congenitally missing teeth? Yes No Don't know Chipped or injured primary or permanent teeth? Yes No Don't know Any sensitive or sore teeth? Yes No Don't know Bleeding gums, bad taste or mouth odor? Yes No Don't know Jaw fractures, cysts, infections? Yes No Don't know Any teeth treated with root canals or pulpotomies? Yes No Don't know "Gum boils,” frequent canker sores or cold sores? Yes No Don't know History of speech problems or speech therapy? Yes No Don't know Difficulty breathing through nose? Yes No Don't know Food impaction between the teeth? Yes No Don't know Mouth breathing habit or snoring at night? Yes No Don't know History of speech problems? Yes No Don't know Frequent oral habits (sucking finger, chewing pen, etc.)? Yes No Don't know Teeth causing irritation to lip, cheek or gums? Yes No Don't know Abnormal swallowing (tongue thrust)? Yes No Don't know Tooth grinding or clenching? Yes No Don't know Clicking, locking in jaw joints? Yes No Don't know Soreness in jaw muscles or face muscles? Yes No Don't know Ringing in ears, difficulty in chewing or opening jaw? Yes No Don't know Have you ever been treated for “TMJ” or “TMD” problems? Yes No Don't know Any broken or missing fillings? Yes No Don't know Any serious trouble associate with previous dental treatment? Yes No Don't know Have you ever been diagnosed with gum disease or pyorrhea? Yes No Don't know Have you ever had an orthodontic consultation or treatment before now? Yes No Don't know Have you had allergies or reactions to any of the following:Local anesthetics (novocaine, lidocaine, xylocaine) Yes No Don't know Latex (gloves, balloons) Yes No Don't know Aspirin Yes No Don't know Ibuprofen (Motrin, Advil) Yes No Don't know Penicillin Yes No Don't know Other antibiotics Yes No Don't know Metals (jewelry, clothing snaps) Yes No Don't know Acrylics Yes No Don't know Plant pollens Yes No Don't know Animals Yes No Don't know Foods Yes No Don't know Other substances Yes No Don't know PATIENT HEALTH INFORMATIONList any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.MedicationTaken for Have you ever taken any medications to strengthen your bones? Please describe.Do you take antibiotic pre-medication before any dental procedures? Yes No Do you or have you ever had a substance abuse problem?Do you chew or smoke tobacco?Have you noticed any changes in your face or jaws?Any other physical problems?How often do you brush?How often do you floss?Women: Are you pregnant? Yes No Are you trying to become pregnant? Yes No FAMILY MEDICAL HISTORYHave your parents or siblings ever had any of the following health problems? If so, please explain.Bleeding disordersDiabetesArthritisSevere allergiesUnusual dental problemsJaw size imbalanceOther family medical conditions?RELEASE AND WAIVERI authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.SignatureDate I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.SignatureDate MEDICAL HISTORY UPDATES OR CHANGESChangesPatient SignatureDate Dental Staff SignatureDate ChangesPatient SignatureDate Dental Staff SignatureDate ChangesPatient SignatureDate Dental Staff SignatureDate Captcha Medical Dental History Form for Patients Under Age 18 PatientDate Name First Last Prefers to be calledHobbies, ActivitiesBirthdate Sex Male Female Social Insurance NumberSchoolGradeEmail Home AddressCity, State, Zip CodeHome PhoneCell PhonePARENT/GUARDIANCustodial Parent(s) Name(s)Patient Lives With (check all that apply) Mother Father Stepmother Stepfather Grandparents Other Father's Full NameOccupationEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhoneMother's Full NameOccupationEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneCell PhoneWork PhoneDENTISTPatient's DentistAddress, City, State, ZIPLast SeenReasonNext AppointmentOther Dentists Now Being SeenCity, StateReasonGENERAL INFORMATIONWhat concerns you have about your child’s teeth?What concerns your child have about his/her teeth?How does your child feel about orthodontic treatment?Who suggested that your child might need orthodontic treatment?Why did you select our office?Describe any previous orthodontic treatment or consultations.Does your child play a musical instrument?Brother/Sister Name and AgeHad orthodontic treatment?If yes, where?Brother/Sister Name and AgeHad orthodontic treatment?If yes, where?Brother/Sister Name and AgeHad orthodontic treatment?If yes, where?Brother/Sister Name and AgeHad orthodontic treatment?If yes, where?Have any other family members been treated in this office? Please name them.FINANCIAL RESPONSIBILITYWho is financially responsible for this account?Address (if different from page 1)City, StateHome PhoneCell PhoneEmail Social Security NumberEmployerWho will be responsible for bringing the patient to orthodontic appointments?DENTAL INSURANCEPrimary policy holder’s full nameBirth Date Social Security NumberRelationship to PatientAddress and phone (if not listed above)EmployerInsurance CompanyGroup NumberID NumberDoes this policy have orthodontic benefits? Yes No Don't Know Secondary policy holder’s full nameBirth Date Social Security NumberRelationship to PatientAddress and phone (if not listed above)EmployerInsurance CompanyGroup NumberID NumberDoes this policy have orthodontic benefits? Yes No Don't Know MEDICAL INSURANCEPolicy holder’s full name (Medical Insurance)Insurance companyPHYSICIANPatient’s PhysicianCity, StateLast seenReasonNext appointmentMost recent physical examName of other physicians/health care providers being seen now:City, StateReasonName of other physicians/health care providers being seen now:City, StateReasonYour answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).MEDICAL HISTORYNow or in the past, has your child had Birth defects or hereditary problems? Yes No Don't know Bone fractures, or major injuries? Yes No Don't know Any injuries to face, head, neck? Yes No Don't know Arthritis or joint problems? Yes No Don't know Cancer, tumor, radiation treatment or chemotherapy? Yes No Don't know Endocrine or thyroid problems? Yes No Don't know Diabetes or low sugar? No Yes Don't know Kidney problems? Yes No Don't know Immune system problems? Yes No Don't know History of osteoporosis? Yes No Don't know Gonorrhea, syphilis, herpes, sexually transmitted diseases? Yes No Don't know AIDS or HIV positive? Yes No Don't know Hepatitis, jaundice or other liver problems? Yes No Don't know Polio, mononucleosis, tuberculosis, pneumonia? Yes No Don't know Seizures, fainting spells, neurologic problem? Yes No Don't know Mental health disturbance or depression? Yes No Don't know History of eating disorder (anorexia, bulimia)? Yes No Don't know Frequent headaches or migraines? Yes No Don't know High or low blood pressure? Yes No Don't know Excessive bleeding or bruising tendency, anemia? Yes No Don't know Chest pain, shortness of breath, tire easily, swollen ankles? Yes No Don't know Heart defects, heart murmur, rheumatic heart disease? Yes No Don't know Angina, arteriosclerosis, stroke or heart attack? Yes No Don't know Skin disorder (other than common acne)? Yes No Don't know Does your child eat a well-balanced diet? Yes No Don't know Vision, hearing, or speech problems? Yes No Don't know Frequent ear infections, colds, throat infections? Yes No Don't know Asthma, sinus problems, hayfever? Yes No Don't know Tonsil or adenoid condition? Yes No Don't know Does your child frequently breathe through his/her mouth? Yes No Don't know Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? Yes No Don't know Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders? Yes No Don't know Has your child had allergies or reactions to Local anesthetics (novocaine, lidocaine, xylocaine) Yes No Don't know Allergies to Latex (gloves, balloons) Yes No Don't know Allergies to Aspirin Yes No Don't know Ibuprofen (Motrin, Advil) Yes No Don't know Allergies to Penicillin Yes No Don't know Other antibiotics Yes No Don't know Metals (jewelry, clothing snaps) Yes No Don't know Acrylics Yes No Dont know Plant pollens Yes No Don't know Animals Yes No Don't know Foods Yes No Don't know Other substances Yes No Don't know DENTAL HISTORYNow or in the past, has the patient had Erupting teeth very early or very late? Yes No Don't know Primary (baby) teeth removed that were not loose? Yes No Don't know Permanent or extra (supernumerary) teeth removed? Yes No Don't know Supernumerary (extra) or congenitally missing teeth? Yes No Don't know Chipped or injured primary or permanent teeth? Yes No Don't know Any sensitive or sore teeth? Yes No Don't know Any lost or broken fillings? Yes No Don't know Jaw fractures, cysts, infections? Yes No Don't know Any teeth treated with root canals or pulpotomies? Yes No Don't know Frequent canker sores or cold sores? Yes No Don't know History of speech problems or speech therapy? Yes No Don't know Difficulty breathing through nose? Yes No Don't know Mouth breathing habit or snoring at night? Yes No Don't know History of speech problems? Yes No Don't know Frequent oral habits (sucking finger, chewing pen, etc.)? Yes No Don't know Teeth causing irritation to lip, cheek or gums? Yes No Don't know Tooth grinding or clenching? Yes No Don't know Clicking, locking in jaw joints? Yes No Don't know Soreness in jaw muscles or face muscles? Yes No Don't know Has your child been treated for “TMJ” or “TMD” problems? Yes No Don't know Any broken or missing fillings? Yes No Don't know Any serious trouble associated with previous dental treatment? Yes No Don't know Has your child ever been diagnosed with gum disease or pyorrhea? Yes No Don't know PATIENT HEALTH INFORMATIONDo you think that any of your child’s activities affect his/her face, teeth or jaws? How?List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.MedicationTaken for Do you take antibiotic pre-medication before any dental procedures? Yes No Does the patient currently have (or ever had) a substance abuse problem?Does your child chew or smoke tobacco?Have you noticed any unusual changes in your child’s face or jaws?Any other physical problems?FAMILY MEDICAL HISTORYHave the parents or siblings ever had any of the following health problems? If so, please explain.Bleeding disordersDiabetesArthritisSevere allergiesUnusual dental problemsJaw size imbalanceOther family medical conditions?How often does your child brush?Floss?RELEASE AND WAIVERI authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.Parent/Guardian SignatureDate I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.Parent/Guardian SignatureDate MEDICAL HISTORY UPDATESChangesParent/Guardian SignatureDate Dental Staff SignatureDate ChangesParent/Guardian SignatureDate Dental Staff SignatureDate ChangesParent/Guardian SignatureDate Dental Staff SignatureDate Captcha Confidential Questionnaire Form CONFIDENTIAL INFORMATION QUESTIONNAIREPatient's Legal NameLast Name*First Name*MI*Prefer to be called*Date of Birth* Sex*MaleFemaleHome Phone NumberCell Phone NumberPatient's AddressStreetApartment NumberCityStateZip CodeEmail Marital Status* Single Married Widowed Divorced Under Age 18 Patient's/Guardian's EmployerOccupationWork AddressStreetApartment NumberCityStateZip CodeWork Phone NumberSpouse's NameLast nameFirst nameMiddle InitialSpouse's employerOccupationSpouse's work addressStreetApartment numberCityStateZip codeWork Phone NumberOther family members that are patients hereWho can we thank for referring you to our office?EMERGENCY CONTACT INFORMATIONPerson we may contact in case of an emergency (other than your family home)NameRelationshipHome Phone NumberWork Phone NumberCellphone NumberREQUEST FOR CONFIDENTIAL COMMUNICATIONAs my dental care provider, you may do the following with my permission:Contact me at home Yes No Contact me via cell phone Yes No Contact me at work Yes No Contact me via e-mail Yes No Leave messages on my home voicemail/answering machine Yes No Leave messages on my cell phone voicemail Yes No Leave messages on my work voicemail/answering machine Yes No INSURANCE AND FINANCIAL INFORMATIONInsurance coverage* Yes No Insurance company nameInsurance addressInsurance phoneSubscriber's NameSubscriber's BirthdaySubscriber's SSN/ID NumberPatient's relationship to subscriber Self Spouse Dependent Group/Program numberEmployer (if different from above)Employer's addressSecondary Coverage Yes No Insurance company nameInsurance addressInsurance phoneSubscriber's NameSubscriber's BirthdaySubscriber's SSN/ID NumberPatient's relationship to subscriber Self Spouse Dependent Group/Program numberEmployer (if different from above)Employer's addressCONFIRMATIONSDo you prefer a confirmation call* No, it is unnecessary Yes, it is a helpful reminder ASSIGNMENT & RELEASEI hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.SIGNATURE - Patient/Guardian*Date WITNESS SIGNATURE*Date Captcha
