Health History Questionnaire
HIPAA Compliant Form
Please complete the form below in full
and submit at the end and everything we're ready to go!
Patient Name
*
First Name
Last Name
Patient Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Patient Gender
*
Patient Gender
Male
Female
Other
Patient's Social Security #
xxx-xx-xxxx
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
*
-
Area Code
Phone Number
Patient's Email
example@example.com
Responsible Party Information
*
Name
Street Address
City
State / Province
Postal / Zip Code
Relationship to Patient
Date of Birth mm/dd/yyyy
*
Employer
Parent/Guardian Preferred Contact Email
*
Responsible Party's Cell Phone
*
-
Area Code
Phone Number
Responsible Party 2 Information
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
-
Month
-
Day
Year
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Employer
Relationship to Patient
Whom may we thank for referring you
*
ex: Dr. Brown or my friend or Google
Please list any family members who are already patients.
My sister or brother or mom or dad or cousin or aunt or uncle or neighbor!
Are there others in the family that may need treatment?
Any children 7 years and older are recommended by AAO for orthodontic consultation!
Reason for seeing the doctor:
*
ex: New Patient Consultation, Routine Growth Check-up, Adjustment, etc.
Parent/Guardian Name
*
First Name
Last Name
Dental Insurance Information. If no insurance please enter X on all options
*
Dental Insurance Company (please include state if Delta Dental)
Subscriber Name
Subscriber DOB
Member ID#
Group#
Parent/Guardian Social Security #
xxx-xx-xxxx
Secondary Dental Insurance Information
Dental Insurance Company (please include state if Delta Dental)
Subscriber Name
Subscriber DOB
Member ID#
Group#
Dentist information
*
Name of General Dentist
Address
City
Zip code
Phone Number
Date of Last Visit
Medical History
Physician's Name
*
Please list any drug, metal, shellfish or latex allergies
ex: Penicilin, latex, nickel, etc.
Has the patient ever had (Please check all that apply)
Anemia
Asthma
Cancer
Diabetes
Epilepsy Seizures
ADHD
Heart Disease
Heart Attack
High Blood Pressure
Ulcer Disease
Hepatitis
Sleep Apnea
Thyroid Problems
Tuberculosis
Gallstones or Kidney Stones
Osteoporosis or bone disorder
HIV
Herpes
Prolonged Bleeding
Rheumatic Fever
Radiation/Chemotherapy
Immune compromise
Drugs/Alcohol
Hemophilia
Please list if you have other illnesses not mentioned above:
Please list any operations/hospitalizations and dates of each:
Please list any current medications
Healthy Dental and Lifestyle Habits
Do you regularly visit your dentist for check-ups?
*
Yes
No
No and please refer me to somebody amazing!
Any prior periodontal or oral surgeries?
*
Yes
No
No but I think I need something in the future
Do your jaws ever hurt when you wake up in the morning?
*
Yes
No
Kind of but not sure
Do you have chronic ringing in your ears?
*
Yes
No
Kind of but not sure
Have you ever been told you grind your teeth?
*
Yes
No
I think so, maybe
Have you ever seen an orthodontist before?
*
Yes
No
Other
Include other comments regarding your Medical, dental, and orthodontic history:
Date
*
-
Month
-
Day
Year
Date Picker Icon
Signature
Clear
Submit
Should be Empty: