Patient Health History

Patient Health History
Patient Full Name (Last, Middle, First)

Last NameMiddle NameFirst Name
Date

MonthDayYear
Date
Social Security
Birth Date

MonthDayYear
Date
Phone
Work Phone
Please enter a valid phone number.
Ext
Emergency Contact#
Preferred appointment times

MorningAfternoonEveningAny time
Anytime
Address
City
State
Zip Code
Referral Information
Whom may we thank for referring you to our practice?

Another patient, relativeAnother patient, friend
Whom may we thank for referring you to our practice?

Dental OfficeYellow PagesNewspaperSchoolWork
Other
Name of person or office referring you to our practice
Medical Information
Have you ever had any of the following? Please check those that apply

AidsAllergiesAnemiaArtiritisArtificial JointsAsthmaBlood DiseaseCancerDiabetesDizzinessEpilepsyExcessive BleedingFaintingGlaucomaGrowthsHay FeverHead InjuriesHeart DiseaseHeart MurmurHepatitisHigh Blood PressureJaundiceKidney DiseaseLiver DiseaseMental DisordersNervous DisordersPacemakerPregnancyRadiation TreatmentRespiratory ProblemsRheumatic FeverRhematismSinus ProblemsStomach ProblemsStrokeTuberculosisTumorsUlcersVenereal DiseaseCodeine AllergyPenicillin Allergy
Allergies:
Due Date

MonthDayYear
Date
Current Medications:
Stomach Problems
Are you now under the care of a physician? If yes, please explain

YesNo
If yes, Please explain
Do you have any health problems that need further clarification? If yes, please explain

YesNo
If yes, Please explain
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
Signature of patient, parent or guardian

Clear
Date

MonthDayYear
Spouse Or Responsible Party Information
Name

First NameLast Name
The following is for:

MaleFemaleMarriedSingleChildOther
The patient's spouse

The following is for
The patient's spouse

the person responsible for payment
Social Security #
Birth Date

MonthDayYear
Date
Phone (Home)
Phone (Work)
Ext
Best time to call
Address
City
State
Zip Code
Apartment #
Employment Information
The following is for

The patientThe person responsible for payment
Employer name
Group Number
Dental Insurance Company
Phone
Dental History
Name of Dentist
Phone
Please enter a valid phone number.
Do you have any current dental problems?
1) Date of last complete dental examination

MonthDayYear
Date
2) Are your teeth sensitivie?
3) Do your gums bleed or hurt?
4) Have you ever had orthodontic treatment?
5) Have you ever seen a periodontist?
6) Have you been told you have a TMJ problem?
7) Do you feel nervous about having dental treatment?
If yes, what is your biggest priority ?
8) Are you happy with the appearance of your teeth?
If no, what would you like to change?
Consent for Services
1)I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis.

2)I agree to be responsible for payment of all services on my behalf or my dependents, including any unpaid insuarance benefits I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a $30.00 late charge may be added to my account.

3)I hereby give Lisa Grant Orthodontics the absolute right and permission to use my photographs / slides for educational or promotional purposes via print or social media. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.

I have a clear understanding of the treatment recommended by the doctor and agree to move forward with the recommended treatment
Signature of patient, parent or guardian

Clear
Date

MonthDayYear
Date
Relationship to Patient
Should be Empty:

Patient Health History

Referral Information

Medical Information

Spouse Or Responsible Party Information

Employment Information

Dental History

Consent for Services