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PATIENT INFORMATION FOR PATIENTS UNDER 18 YEARS OF AGE
Date______
Patient’s name______
LastFirstMiddle
Address______
StreetCityZip
Nickname______Birthdate______Social Security #______
School______Sports/Hobbies______
Parent or guardian name______
Whom may we thank for referring you to our office?______
RESPONSIBLE PARTY INFORMATION
Name______
LastFirstMiddle
Residence______
StreetCityZip
Mailing Address______
StreetCityZip
How long at this address?______Home phone______Work phone______
Cell/other phone______Email address______
Previous Address (If less than 3 years)______
Social Security #______Birthdate______Relationship to Patient______
Employer______Occupation______No. years employed______
Spouse’s Name______Relationship to Patient______
Employer______Occupation______No. years employed______
Social Security #______Birthdate______Work Phone______
DENTAL INSURANCE INFORMATION
Insured’s Name______Insured’s Social Security #______
Insurance Company______Group No.______Local No.______
Insurance Co. Address______Phone No.______
Do you have dual coverage? Yes_____ No_____ If yes:
Insured’s Name______Insured’s Social Security #______
Insurance Company______Group No.______Local No.______
Insurance Co. Address______Phone No.______
EMERGENCY INFORMATION
Name of nearest relative not living with you______
Complete address______
StreetCityZip
Phone______
I understand that, where appropriate, credit bureau reports may be obtained.
Parent Signature ______
Updates (date & initial)______
MEDICAL HISTORY
Physician______Date of Last Visit______
Address______Phone______
Please circle Yes or No (If Yes, please fill in details)
YesNoIs the patient taking any medication? ______
YesNoIs the patient allergic to any medication? ______
YesNoHistory of a major illness?______
YesNoHas the patient had any operations?______
YesNoEver been involved in a serious accident?______
YesNoHave seen a physician in the last 12 months? Why?______
Female Patients only:
YesNoHas menstruation started?______
YesNoIs the patient pregnant?______
Circle any of the medical conditions below that the patient has had or currently has.
Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumonia
AnemiaDizzinessHerpesProlonged Bleeding
ArthritisEpilepsyHigh Blood PressureRadiation/Chemotherapy
Asthma or HayfeverGastrointestinal DisordersHIV / AidsRheumatic Fever
Bone DisordersHeart ProblemsKidney problemsTuberculosis
Congenital Heart DefectHeart MurmurNervous DisordersTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?______
______
DENTAL HISTORY
General Dentist______Date of last visit______
What concerns you most about your teeth?______
YesNoIs the patient presently in any dental pain?______
YesNoEver experienced any unfavorable reaction to dentistry?______
YesNoHas the patient ever lost or chipped any teeth?______
YesNoHave there been any injuries to face, mouth, or teeth?______
YesNoIs any part of your mouth sensitive to temperature? Where?______
YesNoIs any part of your mouth sensitive to pressure? Where?______
YesNoDo gums bleed when brushing?______
YesNoAny type of thumb or tongue habit?______
YesNoIs the patient a mouth breather?______
YesNoHasthe patient ever seen an orthodontist? If yes, who and when?______
YesNoWhat is the patient’s attitude toward receiving orthodontic treatment?______
YesNoHas anyone in the family received orthodontic treatment?______How did they feel about the result?
YesNoDo teeth or jaws ever feel uncomfortable first thing in the morning?______
YesNoExperience jaw clicking or popping?______
YesNoAware of clenching or grinding teeth during the day?______
YesNoExperience “tension” headaches?______
YesNoHas the patient ever experienced chronic ringing in the ears?______
YesNoDoes the patient need extra help with instructions?______
YesNoIs the patient sensitive or self-conscious about his/her teeth?______
YesNoHeight of parents? Mom______Dad______
YesNoAre you aware that some appointments will be during school hours?______
Signature:______Date:______