New Patient Health History

[Pages:2]New Patient Health History

First Name: Nickname: Address:

Main Phone:

Patient Biographical Information

Middle Initial:

Last Name:

Birthdate: City:

Gender:

State:

Zip:

2nd/Cell Phone:

Email:

Social Security #: 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 practice?

First Name:

Birthdate: Address:

Main Phone:

Employer: Work Phone: Do you have insurance that covers orthodontics?

Yes No

Financial Party Information Middle Initial: Relationship to Patient: City:

2nd/Cell Phone: Occupation:

Last Name:

Email:

State:

Zip:

Social Security #:

Length of Employment:

If so, please name the Insurance Company:

Dental History

Dentist Name: Check-up Frequency: Has the patient had an orthodontic consult or treatment? What is the patient's main orthodontic concern?

Last Dental Visit:

Yes No

If so, when?

Speech problems/therapy?

Yes No

Injury to face, jaw, teeth or mouth?

Yes No

Pain, tenderness or noise in either jaw?

Yes No

Oral Habits (thumb/finger sucking, lip/nail biting)?

Yes No

Frequent sore throats?

Yes No

Floss teeth daily?

Yes No

Mouth Breathing?

Yes No

Requires premedication?

Yes No

Apprehensive about dental care?

Yes No

If any of the above dental questions were answered "Yes," please explain:

Grind or clench teeth? Discomfort from teeth or gums? Frequent headaches? Neck/shoulder pain? Brush teeth daily? Fluoride treatments? Snores during sleep? Any missing or extra permanent teeth? Frequently chew gum?

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Medical History

Physician Name: Address:

Date of last Physical:

City:

State:

Patient Health: Zip:

List any medications currently being taken by the patient: List any drug allergies or sensitivities that the patient may have:

Rheumatic Fever

Yes No

Tuberculosis/Lung Disease

Pneumonia

Yes No

Liver Disease

Kidney Disease

Yes No

Heart Attack/Stroke

Heart Disease

Yes No

Congenital Heart Defect

Heart Murmur

Yes No

Hemophilia

Hypertension/High Blood Pressure

Yes No

Prolonged Bleeding/Transfusion

Anemia

Yes No

HIV/AIDS

Hepatitis

Yes No

Tonsils/Adenoids Removed

Cancer

Yes No

Family History of Cancer

Received Radiation Treatment

Yes No

Growth Problems

Endocrine Problems

Yes No

Hormone Therapy

Latex/Metal Allergy

Yes No

Nervous Disorders

Bone Disorders/Bone Loss

Yes No

Diabetes

Seizures/Epilepsy

Yes No

Handicaps/Disabilities

Asthma

Yes No

Arthritis

Treated for Emotional Problems

Yes No

Ever Been Hospitalized

If any of the above medical questions were answered "Yes," please explain:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Patients Under 18

Please list the name and birth date of any siblings:

Height:

W eight:

Father/Guardian 1 Name:

School: Mother/Guardian 2 Name:

Has patient begun puberty? If patient is a girl, has menstruation begun? If patient is a boy, has their voice changed or have facial hair? Has the patient grown in the past year or has their shoe size changed recently? Patient's interest in treatment? Has either biological parent ever had orthodontic treatment?

Yes No Yes No Yes No Yes No

Yes No

Grade:

Signature: ______________________________________________ Date: ________

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