Health History Form
Complete your health history information online and save time at the doctor's office! Please take a 10-15 minutes to fill out this confidential form with secure encryption. Once submitted, your information will be readily available at your first appointment.
Are you completing this form for yourself or on behalf of someone else?
I'm completing this form myself.
I'm completing this form on behalf of someone else. (I'm the parent, guardian, etc.)
Parent or Guardian's Name (if patient is a minor)
First Name
Middle Name
Last Name
Patient Information
Patient's Name
*
First Name
Last Name
I preferred to be called
Nickname
Gender
*
Male
Female
Preferred Pronoun(s)
Birth Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Email
*
example@example.com
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell/Other Phone
*
Please enter a valid phone number.
How did you hear about us?
*
Facebook
Instagram
Yelp
Google
YouTube
General Dentist
Patient of Holliday Orthodontics
Television
Other
Name Of Referral
Name of patient of Holliday Orthodontics, General dentist etc.
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Responsible Billing Party Information
Who will be financially responsible for your account?
*
Self
Spouse
Mother
Father
Other
Billing Party Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Marital Status
*
Single
Married
Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Is Mailing Address the same as Residential Address?
*
Yes
No
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long have you lived at this address?
*
Years
Previous Address (if less than 3 years)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell/Other Phone
*
Please enter a valid phone number.
Employer
*
Occupation
Number of Years Employed
*
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Next
Spouse Information
Spouse's Name
First Name
Last Name
Spouse's Birth Date
-
Month
-
Day
Year
Date
Spouse's Relationship to Patient
Spouse's Email
example@example.com
Spouse's Home Phone
Please enter a valid phone number.
Spouse's Work Phone
Please enter a valid phone number.
Spouse's Cell/Other Phone
Please enter a valid phone number.
Spouse's Employer
Spouse's Occupation
Number of Years Employed
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Next
Dental Insurance Information
Do you have dental insurance?
*
Yes
No
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Next
Dental Insurance Information
Insured's Name
*
First Name
Last Name
Insured's Social Security Number (U.S. only)
Birth Date
*
-
Month
-
Day
Year
Date
Insurance Company
*
Group Number
ID/Policy #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
Do you have dual coverage?
Yes
No
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Next
Dual Coverage Dental Insurance Information
Insured's Name
*
First Name
Last Name
Insured's Social Security Number (U.S. only)
Birth Date
*
-
Month
-
Day
Year
Date
Insurance Company
*
Group Number
ID/Policy #
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Phone Number
Please enter a valid phone number.
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Next
Emergency Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Relationship to Patient
*
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Next
Patient Medical History
Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.
Physician Name
First Name
Last Name
Physician Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Physician Phone Number
Please enter a valid phone number.
Date of Last Visit
-
Month
-
Day
Year
Date
Please check any of the following that you have had or currently have:
*
Abnormal bleeding/Hemophilia
Alcohol
Arthritis
Asthma
Bone Disorders (Osteoporosis)
Bisphosphonates
Diabetes
Dizziness
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
High Blood Pressure
HIV/AIDS
Joint Pain, Stiffness
Radiation/Chemotherapy
Rheumatic Fever
Ringing in Ears
Seizures
Tobacco
Tuberculosis
Tumor or Cancer
None
Other
Are there any medical conditions we have not discussed that you feel we should be aware of?
*
Yes
No
Please list medical conditions:
Are you taking any drugs, medicines, or recreational drugs (including Aspirin)?
*
Yes
No
Please list drugs, medicines, or recreational drugs:
Are you allergic to latex?
*
Yes
No
Are you allergic to any medication?
*
Yes
No
Please list medication you are allergic to:
Any other allergies we should be aware of?
*
Are you or could you be pregnant?
*
Yes
No
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Dental History
Do you currently see a dentist?
*
Yes
No, I will need a referral
Dentist
*
Date of Last Visit
*
-
Month
-
Day
Year
Date
Dentist Telephone Number
*
Please enter a valid phone number.
What concerns you most about your teeth?
Please check any of the following which apply to you, and add any relevant comments.
*
Yes
No
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to your face, mouth, or teeth?
Is any part of your mouth sensitive to temperature?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaws clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have 'tension' headaches?
Have you ever experienced chronic ringing in your ears?
Please add any relevant comments below:
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Next
Orthodontic History
Are you currently in braces?
Yes
No
Have you ever seen an orthodontist?
Yes
No
If yes, who?
When did you see this orthodontist?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?
Yes
No
If so, who?
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HIPAA Omnibus Rule: Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent / Limited Authorization & Release Form
You may refuse to sign this acknowledgment and authorization. In refusing, we may not be allowed to process your insurance claims. The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.
Please list any other parties who can have access to your health information This includes step-parents, grandparents, and any caretakers who can have access to the patient's records. Please provide name and relationship (i.e. John Doe, Grandpa).*
First Name
Last Name
Relationship
Person 1
Person 2
Person 3
I authorize contact from this office to confirm my appointments, treatment, and billing information via:
*
Cell phone confirmation
Home phone confirmation
Work phone confirmation
Text messaging (SMS)
Email
Any of the above
I authorize information about my health to be conveyed via:
*
Cell phone
Home phone
Work phone
Text messaging (SMS)
Email
Any of the above
I approve being contacted about special services, events, fundraising efforts or new health info on behalf of this healthcare facility via:
Phone message
Text messaging (SMS)
Email
Any of the above
None (opt-out)
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Patient/Guardian Signature
To the best of my knowledge, I have answered every question completely and accurately. I will inform my orthodontist of any change in my health and/or medication.
Patient/Guardian Signature
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: