Patient Information Form

Patient Information Form
Patient Name*

First NameLast Name
Common Name
Gender

MaleFemale
Age
Birth Date

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (If under 18)
Phone Number*
Please enter a valid phone number.
Cell Carrier
Email Address*
example@example.com
Responsible Party's Information
Name

First NameLast Name
Marital Status

SingleMarriedWidowedDivorcedSeparated
Birth Date

MonthDayYear
Date
Relation to patient
Mailing Address (If different from patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Do you own or rent?

OwnRent
Previous Address (if less than 3 yrs)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Work Phone
Please enter a valid phone number.
Years Employed
Spouse
Name

First NameLast Name
Birth Date

MonthDayYear
Date
Relation to Patient
Employer
Occupation
Work Phone
Please enter a valid phone number.
Years Employed
Insurance Information
Do you have insurance coverage?*

YesNo
Insured's Name

First NameLast Name
Insured's SSN
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co.
Group No.
Subscriber ID #
Insurance Phone
Please enter a valid phone number.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have Dual Coverage?

YesNo
Insured's Name

First NameLast Name
Insured's SSN
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co.
Group No.
Subscriber ID #
Insurance Phone
Please enter a valid phone number.
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Name of nearest relative not living with you*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I certify that the above information is accurate and I agree to inform this office of any changes to the above information in the future. I understand that, where appropriate, credit bureau reports may be obtained.
Whom may we thank for referring you to our office?
Medical History
Physician
Dentist
Does the patient:
Have any health problems (current or past)*

YesNo
If yes, please explain.
Take any medications (current or past)*

YesNo
If yes, please explain.
Currently see a physician*

YesNo
If yes, please explain.
Have allergies to anything*

YesNo
If yes, please explain.
Have a history of illness or hospitalizations*

YesNo
If yes, please explain.
Use drugs, alcohol or tobacco*

YesNo
If yes, please explain.
Have trouble breathing through the nose*

YesNo
If yes, please explain.
Have a tendency for ear infections*

YesNo
If yes, please explain.
Have a history of bumps to the chin or trauma to the face, teeth or jaws*

YesNo
If yes, please explain.
Have any pain, clicking or noises in the jaw joint or head/neck regions*

YesNo
If yes, please explain.
Experience frequent headaches*

YesNo
If yes, please explain.
Play any wind/reed instruments or the violin*

YesNo
If yes, please explain.
Have negative reactions or experiences to any type of dental work*

YesNo
If yes, please explain.
Need to take medication before dental work because of a heart/valve condition*

YesNo
If yes, please explain.
Have airway concerns or been diagnosed with Sleep Apnea*

YesNo
If yes, please explain.
Have a history of thumb sucking, if yes, until what age?*

YesNo
If yes, please explain.
Has the patient ever had any of the following:*

Heart Trouble, Congenital Heart LesionsHeart MurmurHigh or Low Blood PressureRheumatic Fever, Heart Valve ProblemsArteriosclerosis or StrokeChest Pains or mild exertionShortness of Breath on mild exertionKidney Disease or problemsExcessively Swollen Ankles or TissuesAnorexia, BulimiaVenereal DiseaseScarlet FeverLiver DiseaseHepatitis, Jaundice, Liver ProblemsHearing Problems, Ringing in the EarsCold Sores, Herpetic Lesions, CankersSkin Rash, Lesions, Hives, Fever BlistersProstate DisordersGlaucoma, CataractsSudden Weight ChangeBlood TransfusionDiabetes or a Family History of sameExcessive Chronic ThirstThyroid Disorders or Family HistoryEndocrine DisturbancesAnemia, Blood DiseasesBleeding Disorders, Prolonged BleedingArthritis, Sore or Swollen JointsTuberculosis, Chronic or Frequent CoughMononucleosis or Other Viral DiseaseHIV Virus or AIDSUlcers, Internal BleedingEmphysema, Breathing ProblemsAsthma, Respiratory ProblemsRadiation Treatment, ChemotherapyMalignancies, Tumors, or GrowthsEpilepsy or SeizuresHyperactivity, NervousnessFainting, Dizziness, UnconsciousnessChronic Exhaustion or FatigueChronic Nervousness, High StressChronic Unhappiness or DepressionEmotional Problems or TensionPsychiatric TreatmentNone
For the Female Patient...is the patient now:
Pregnant?

YesNo
Taking Birth Control?

YesNo
Have you ever taken Bisphosphonates for bone density?

YesNo
Are you currently taking Bisphosphonates?

YesNo
Please explain fully any “Yes” answers above or any family history of any of the above conditions.
Please explain your orthodontic concerns and what you would like orthodontics to accomplish for you.
Signature

I certify that the information above is true and accurate and that if there are any changes in this medical history, I will notify this office. I agree to allow Dr. Chandler and/or Dr. Anderson to discuss or share this information with whomever they deem necessary
Patient/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Information Form

Responsible Party's Information

Spouse

Insurance Information

Emergency Information

Medical History

Does the patient:

For the Female Patient...is the patient now:

Signature