Patient information

PATIENT INFORMATION
Patient’s Full Name__________________________________________ Date of Birth_______________ Age_______ Sex______
Address______________________________________________City/State_________________________Zip Code___________Home Phone_________________________________ SSN_________ ____________ Email_____________________________________ Names of friends or relatives who were former patients___________________________________________________________Who may we thank for referring you to our office? _____________________________________________________________ Patient’s Dentist__________________________________ Patient’s Physician_______________________________________
INSURANCE INFORMATION
Insured’s Name_________________________________ Date of Birth ___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________ Insured’s Name_________________________________ Date of Birth___________ Insured's Social Security #_______________Insurance Company_____________________________________________ Group #_____________Local #_________________Insurance Company Address_________________________________________________________________________________Insurance Company Phone #______________________________Insured's Employer___________________________________ DENTAL HISTORY
Does patient receive regular dental checkups? YES NOLast dental exam___________________________________ Last dental x-rays_________________________________________Has patient received any previous orthodontic consultation or treatment?____________________________________________How often does patient brush their teeth?_______________________ Is floss used?_____________ How often?_____________Does the patient currently have, or has the patient ever had any of the fol owing? Any clicking, popping or pain of jaw, joints (TMJ) What?_______________________________________________ What are you or your Dentist most concerned about? (Purpose of visit)______________________________________________ ________________________________________________________________________________________________________ CONTINUED ON BACK --------->
ORAL HISTORY
The fol owing are some habits commonly found which may influence tooth position. List info as pertains to patient: Other habits______________________________________________________________________________________________ Has patient ever had any speech therapy?______________________________________________________________________ List any musical wind instruments played_______________________________________________________________________ HEALTH HISTORY
Has patient been under the care of a physician during the past two years? (other than routine checks) If yes, what for?___________________________________________________________________________________________Is patient currently taking medications?________________________________________________________________________Is patient al ergic to anything (drugs, food, pol en, etc.)?___________________________________________________________ Does the patient currently have, or has the patient ever had any of the fol owing?Y N Tonsils Removed Have you been diagnosed or treated for osteoporosis? Y N If yes, have you ever taken or are you now currently taking: Fosamax Didronel Boniva Actonel Reclast or a generic form of Bisphosphonates Does the patient have any special problems not listed above? ______________________________________________________ ________________________________________________________________________________________________________ EMERGENCY INFORMATION
Name of emergency contact person_____________________________________________________________________Relation____________________________________________ Phone #_____________________

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