PATIENT INFORMATION

 

* Patient's Name (last, first, middle, Suffix/Title)

* Address (Street, City, Zip)

* Date of Birth

* Male/Female

* SSN

Home Phone

* Mobile Phone

* Mobile Carrier

* Email

* Work Phone

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

Whom may we thank for referring you to our office?

Name of General Dentist or Pediatric Dentist

Hobbies/Interests

Names of other siblings?

 

RESPONSIBLE PARTY INFORMATION

 

Name (last, first, middle, Suffix/Title)

Home Address (Street, City, Zip)

Work Address (Street, City, Zip)

* Home Phone

* Work Phone

* Email

* Mobile

* SSN

* Date of Birth

* Relationship to patient

* Employer

* Occupation

* Employer

* Occupation

 

DENTAL INSURANCE INFORMATION

 

Policy holder's Name

Date of Birth

SSN

Name of Employer

Policy Holder Address

Does your job offer a “Flexible spending” account?
YesNoDon't Know

What month does it renew?

Insurance Company

Group No.

Insurance Co. Address

Phone No


Do you have dual coverage?
YesNo

If yes complete the following below:

Policy holder’s Name

Date of Birth

Policy holder’s Social Security #

Insurance Company

Group No.

Employer

Insurance Co. Address

Phone No


 

MEDICAL HISTORY OF NEW PATIENT

 

* Patient's Name (last, first, middle, Suffix/Title)

Physician

Date of Last Visit

* Address (Street, City, Zip)

* Phone

 

 

YesNoAre you taking any medication?

YesNoAre you allergic to any medication/latex/or nickel?

YesNoDo you have a history of major illness?

YesNoHave you had any major operations?

YesNoHave you ever been involved in a serious accident?

 

Select any of the medical conditions below that you have had or currently have:

Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumoniaAnemiaDizzinessHerpesProlonged BleedingArthritisEpilepsyHigh Blood PressureRadiation/ChemoAsthma or HayfeverGI problemsHIV/AidsRheumatic FeverBone DisordersHeart ProblemsKidney ProblemsTuberculosisCongenital 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 OF NEW PATIENT

 

Dentist

Date of Last Visit

What concerns you most about your teeth?

 

 

YesNoAre you presently in any dental pain?

YesNoHave you ever experienced any unfavorable reaction to dentistry?

YesNoHave you ever lost or chipped any permanent teeth?

YesNoIs any part of your mouth sensitive to temperature of pressure?

YesNoDo your gums bleed when you brush?

YesNoHas there been any injuries to your face, mouth, or teeth?

YesNoDo you have any kind of thumb or tongue habit?

YesNoAre you a mouth breather?

YesNoHave you ever seen an orthodontist? If yes, who and when?

YesNoWould you object to wearing orthodontic appliances (braces) should they be indicated?

YesNoHas anyone in your family received orthodontic treatment?

YesNoDo your teeth or jaws ever feel uncomfortable when you awake in the morning?

YesNoAre you aware of your jaw clicking or popping?

YesNoAre you aware of clenching your teeth during the day?

YesNoHave you ever been told that you grind your teeth?

YesNoDo you have tension headaches?

YesNoAre you aware that some appointments will be during school or work hours?

 
 

For FEMALE Patients Only:

YesNoAre you pregnant?

YesNoHas menstruation started?

 

 

BENEFITS

 

Benefits of Orthodontics: Esthetics, Beauty, Health, Function, Confidence, and Success. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the function of the teeth, in the dental and medical health of the patient, and in the overall self-esteem and future success of the patient.

I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Gibson to perform a complete orthodontic evaluation.

Signature (Type your Name here again.)

Date: