New Patient Form (Bigman Ortho)

New Patient Form
PATIENT INFORMATION
Patient's Name*

First NameLast Name
Gender*

MaleFemale
Birthdate*

MonthDayYear
Date
Patient Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Patient's interests
Name/Age of brothers & sisters
Whom may we thank for referring you to our office?
School currently attending
RESPONSIBLE PARTY INFORMATION
Email*
example@example.com
Marital Status*
Parent/Guardian #1*

First NameLast Name
Relationship to Patient*
SSN*
Birthdate*

MonthDayYear
Date
Mailing Address (if different than above)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?*
Home Phone*
Please enter a valid phone number.
Work/Cell Phone
Please enter a valid phone number.
Previous Address (if less than 3 yrs)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer*
Occupation*
No. Years Employed*
Parent/Guardian #2*

First NameLast Name
Birthdate

MonthDayYear
Date
Work/Cell Phone
Please enter a valid phone number.
Employer
Occupation
No. Years Employed
DENTAL INSURANCE INFORMATION

Subscriber #1
Subscriber Name #1
SS# or ID# of Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Employer
Insurance Company
Insurance Phone No.
Please enter a valid phone number.
Insurance Group #
DENTAL INSURANCE INFORMATION

Subscriber #2
Subscriber Name #2
SS# or ID# of Subscriber
Subscriber Date of Birth

MonthDayYear
Date
Employer
Insurance Company
Insurance Phone No.
Please enter a valid phone number.
Insurance Group #
I hereby authorize release of any information to other health care providers, as needed, to insurance companies, and business associates including personal health information as well as administrative data. I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. I certify that the information on this form is complete and true to the best of my knowledge. I understand that where appropriate, credit bureau reports may be obtained.
MEMBER
Print Name
Signature

Clear
Date

MonthDayYear
Date
Updated: Print Name
Print Name
Signature

Clear
Date

MonthDayYear
Date
PATIENT'S MEDICAL HISTORY
Primary Physician's Name*
Phone Number*
Please enter a valid phone number.
City*
Are you currently taking any medication?*

YesNo
If yes, please describe.
Are you allergic to any food or medication?*

YesNo
If yes, please describe.
Do you have a history of a major illness or accidents?*

YesNo
If yes, please describe.
Have you had any major operations?*

YesNo
Type a question
Have you ever had your tonsils or adenoids removed?*

YesNo
If yes, please describe.
Have you ever had a concussion?*

YesNo
If yes, please describe.
Are you active in sports? If so, what sports?*

YesNo
If so, what sports?
Are there any medical conditions that we should be aware of?*
Do you have any speech problems or concerns?*
Have you received/are you receiving speech therapy?*
Select any of the medical conditions below that you have had or currently have.*

Abnormal bleeding/HemophiliaADD/ADHDAllergies (Seasonal)/Sinus ProblemsAnemiaArthritisAsthma or HayfeverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsy/SeizuresFrequent coldsGastrointestinal DisordersHeart MurmurHeart ProblemsHepatitis/Liver ProblemsHerpes/Oral-FacialHigh Blood PressureHIV/AidsHyperactivityImmune DeficiencyKidney ProblemsSleep ApneaPneumoniaRadiation/ChemotherapyRheumatic FeverThyroid or Hormonal imbalanceTuberculosisTumor or CancerUlcersVenereal diseaseMetal AllergyNoneNickel or Specify
PATIENT'S DENTAL HISTORY
Dentist's Name*
Phone*
Please enter a valid phone number.
City*
Date of Last Visit*

MonthDayYear
Date
Has your dentist mentioned any concerns? If yes, please describe.*
Are you experiencing any dental pain?*

YesNo
If yes, please describe.
Have you ever experienced any unfavorable reaction to dentistry?*

YesNo
If yes, please describe.
Have you ever lost or chipped any permanent teeth?*

YesNo
If yes, please describe.
Do you have any type of tongue or thumb habit?*

YesNo
If yes, please describe.
Do you breathe mostly through the mouth?*

YesNo
If yes, please describe.
Do you have difficulty staying asleep at night?*

YesNo
If yes, please describe.
Have there been any injuries to your face, mouth or teeth?*

YesNo
If yes, please describe.
Is any part of your mouth sensitive to temperature or pressure?*

YesNo
If yes, please describe.
Do your gums bleed when you brush?*

YesNo
If yes, please describe.
Do you grind or clench your teeth at night?*

YesNo
If yes, please describe.
In the past, have you ever had the following in your jaw or jaw muscles?*

ClickingPoppingStiffnessSorenessNone of these
Episodes when the jaw would not open or close normally?*

YesNo
If yes, please describe.
Pain or discomfort in the front of the ear?*

YesNo
If yes, please describe.
Have you ever experienced chronic ringing in your ears?*

YesNo
If yes, please describe.
Headaches, neck and/or back pain?*

YesNo
If yes, please write date and details:
If the Patient is under the age of 20, what is the height of their parents?
Mom
Dad
For Female patients only: Are you pregnant?

YesNo
For Female patients only: To determine growth pattern,has menstruation started?

YesNo
If so, when?
Signature

Clear
IN CASE OF EMERGENCY PLEASE CONTACT:
Name of nearest relative/friend that we should contact in case of an emergency (within a 20 mile radius):
Name*
Relationship*
Phone*
Please enter a valid phone number.
Reviewed by Dr. Bigman:
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

New Patient Form

PATIENT INFORMATION

RESPONSIBLE PARTY INFORMATION

DENTAL INSURANCE INFORMATION

DENTAL INSURANCE INFORMATION

MEMBER

Updated: Print Name

PATIENT'S MEDICAL HISTORY

PATIENT'S DENTAL HISTORY

If the Patient is under the age of 20, what is the height of their parents?

IN CASE OF EMERGENCY PLEASE CONTACT: