New Patient Form

Patient Information


Patient’s name:


Address:







Responsible Party Information

Name:


Residence:


Mailing Address:








Dental Insurance Information

Do You Have Insurance?YesNo







Emergency Information

Complete address:



Medical History

Physician: Date of Last Visit:
Address: Phone:
Are you taking any medication? (If Yes, please fill in details)
YesNo
Details:
Are you allergic to any medication? (If Yes, please fill in details)
YesNo
Details:
Do you have a history of a major illness? (If Yes, please fill in details)
YesNo
Details:
Have you had any major operations? (If Yes, please fill in details)
YesNo
Details:
Have you ever been involved in a serious accident? (If Yes, please fill in details)
YesNo
Details:

Check any of the medical conditions below that you have had or currently have.
Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumoniaAnemiaDizzinessHerpesProlongedBleedingArthritisEpilepsyHigh Blood PressureRadiation/ChemotherapyAsthma or HayfeverGastrointestinal DisordersHIV / AidRheumatic 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?

Check any of the allergies below that you have had or currently have.
LatexPenicillinCodeineErythromycinTetracyclineAspirinIbuprofenMetalsOther

Check any below that you have had or currently have.
RheumFeverProsthesisConvulsions/epilepsyHearing impairmentHandicaps/disabilitiesHistory of Scarlet Fever

Check any of the child habits your child have.
Thumb sucking/Finger suckinglip Sucking/bitingNail bitingNursing Bottle HabitsTrouble chewing


Dental History

Dentist: Date of last visit:
What concerns you most about your teeth?
Are you presently in any dental pain?
YesNo
Have you ever experienced any unfavorable reaction to dentistry?
YesNo
Have you ever lost or chipped any teeth?
YesNo
Have there been any injuries to face, mouth or teeth?
YesNo
Is any part of your mouth sensitive to temperature or pressure?
YesNo
Do your gums bleed when you brush?
YesNo
Do you have any type of thumb or tongue habit?
YesNo
Are you a mouth breather?
YesNo
Have you ever seen an orthodontist?
YesNo
If yes, who and when?
Would you object to wearing orthodontic appliances (braces) should they be indicated?
YesNo
Has anyone in your family received orthodontic treat ment?
YesNo
How did they feel about the result?
What is your attitude toward receiving orthodontic treatment?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
YesNo
Are you aware of your jaw clicking or popping?
YesNo
Are you aware of clenching your teeth during the day?
YesNo
Have you ever been told that you grind your teeth?
YesNo
Do you have “tension” headaches?
YesNo
Have you ever experienced chronic ringing in your ears?
YesNo
Height of parents? Mom Dad
Has menstruation started?
YesNo
Are you aware that some appointments will be during school/work hours?
YesNo
Please list some hobbies or interests:

Female Patients only:

Are you pregnant?
YesNo

BENEFITS

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result.
Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records and my name may be used for educational and promotional purposes. 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. to perform a complete orthodontic evaluation.
Date:
Signature: