Health History Form
Patient’s Name
*
First Name
Last Name
Age
*
Birth date
*
-
Month
-
Day
Year
Date
Preferred Name
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
School
Grade
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security #
Do you play a musical instrument?
Yes
No
Who may we thank for referring you to our office?
Responsible Party
Name
*
First Name
Last Name
Marital Status
Address: Same as above
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
*
Please enter a valid phone number.
Employer
*
Occupation
*
No. of years employed
Dental Insurance Information
Do you have Dental Insurance?
*
Yes
No
Has this insurance been used for previous orthodontic treatment for this patient?
Yes
No
Primary Subscriber’s Name
*
Primary Subscriber’s SS#
*
D.O.B
*
-
Month
-
Day
Year
Date
Insurance Co
*
Member ID
*
Group #
Insurance Co Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Co Phone
Please enter a valid phone number.
Primary Subscriber’s Employer
Do you have dual coverage?
*
Yes
No
Subscriber’s Name
*
Subscriber’s SS#
*
D.O.B
*
-
Month
-
Day
Year
Date
Insurance Co
*
Member ID
*
Group #
Insurance Co Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Co Phone
Please enter a valid phone number.
Subscriber’s Employer
Medical/Dental History
Dentist’s Name
Phone
Please enter a valid phone number.
Last Cleaning Date
-
Month
-
Day
Year
Date
Physician’s Name
Phone
Please enter a valid phone number.
Are you currently under any medical treatment?
*
Yes
No
Do you have pain, clicking, and/or popping noises in the jaw?
*
Yes
No
Are you aware of either clenching or grinding of teeth?
*
Yes
No
Do you have frequent headaches? How often?
*
Yes
No
Do you have ear problems? (Aches, ringing, dizziness, fullness)
*
Yes
No
Do you have difficulty breathing through the nose?
*
Yes
No
Do you have habits such as nail biting, finger or thumb sucking, lip or cheek biting?
*
Yes
No
Do you have speech problems, or are you in speech therapy?
*
Yes
No
Have you had your tonsils and/or adenoids removed?
*
Yes
No
Is there a tendency to faint or become dizzy?
*
Yes
No
Do you have sleep apnea?
*
Yes
No
Do you smoke or chew tobacco?
*
Yes
No
Have there been any injuries to the teeth?
*
Yes
No
Have you had any permanent teeth extracted?
*
Yes
No
Has there been any history of:
*
Joint swelling
Asthma
TB
Aids
Kidney
Liver Condition
Epilepsy
Rheumatic fever
None
Other major illnesses
Do you have allergies? (Sulphur, Penicillin, Novocain, etc.)
*
Yes
No
If yes, list:
Are you currently taking any medication?
*
Yes
No
If yes, list:
Do you have a heart condition?
*
Yes
No
If yes, do you pre-medicate?
*
Yes
No
Cardiologist:
Have we treated any other family members?
*
Yes
No
Who?
Could you currently be pregnant?
Yes
No
Females under the age of 18: Have you started your menstrual cycle?
*
Yes
No
If yes, at what age?
Signature
I understand where appropriate, a credit report may be obtained.
Signature
*
Clear
Parent/Guardian Name
Patient’s Name
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: