New Patient Health History Form

New Patient Health History
Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
State:
Zip:
Main Phone:
2
nd
/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2
nd
/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone:
Do you have insurance that covers orthodontics?
Yes No
If so, please name the Insurance Company:
Dental History
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? Yes No
If so, when?
What is the patient’s main orthodontic concern?
Speech problems/therapy?
Yes No
Grind or clench teeth?
Yes No
Injury to face, jaw, teeth or mouth?
Yes No
Discomfort from teeth or gums?
Yes No
Pain, tenderness or noise in either jaw?
Yes No
Frequent headaches?
Yes No
Oral Habits (thumb/finger sucking, lip/nail biting)?
Yes No
Neck/shoulder pain?
Yes No
Frequent sore throats?
Yes No
Brush teeth daily?
Yes No
Floss teeth daily?
Yes No
Fluoride treatments?
Yes No
Mouth Breathing?
Yes No
Snores during sleep?
Yes No
Requires premedication?
Yes No
Any missing or extra permanent teeth?
Yes No
Apprehensive about dental care?
Yes No
Frequently chew gum?
Yes No
If any of the above dental questions were answered “Yes,” please explain:
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