Form

Preferred phone number to call for appointments(During Business Hours)

Preferred Email Address

SSN (for accounting purposes only)

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Please upload a picture of your dental insurance card here.

Insurance Card Front

Upload or drag files here

Insurance Card Back

Upload or drag files here

Spouse First Name

M.I.

Spouse Last Name

Spouse Age

Spouse Gender

Spouse Date Of Birth

Employed By

Occupation

Position

Employer Address

City

State

Zip

Work Tel. Phone #

SSN (for accounting purposes only)

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Reponsible Party (if other than the patient/spouse):

Is the responsible party authorized to sign consent on behalf of patient?

Name

SSN

Date Of Birth

Relationship to patient

Address

City

Zip Code

Phone

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Patient's Family Dentist

Patient's Family Physician

Whom may we thank for referring you to our office?

MEDICAL HISTORY

Have you had or do you have any of the following?

Rheumatic Fever

Heart Murmur

High Blood Pressure

Heart Attack/Stroke

Blood Vessel Disease

Blood Disorder

AIDS/HIV Infection

Hepatitis

Diabetes

Ulcers

Herpes (Any type)

Psoriasis

Cancer

Persistent Headaches

Neck Pains

Nerve or Brain Disease

Migraine

Epilepsy

Mental Health Problems

Bone Disorders

Arthritis (Any type)

Artificial Joints

Sleep Apnea

Ear Disorder

Sinus Infection

Swollen Glands

Allergies

Please list any other significant information about your medical history:

Are you under a physician's care at present?

If yes, reason

Are you presently, or have you ever been, under the care of a psychiatrist or psychologist?

If yes, describe

Are you currently taking any medication?

If yes, describe

Are you allergic to any medications? (e,g: aspirin, penicillin, etc.)

If yes, describe

Have you ever had any general anesthesia?

If yes, describe

Do you have regular menstrual cycles?

Have you experienced menopause?

Has anyone in your family had osteoporosis?

Is there a possibility that you could be pregnant?

Do any of your teeth hurt?

If yes,

Have any wisdom teeth been removed?

How many?

Have you ever had treatment for a periodontal disease (gum disease)?

If yes, describe

Have you ever had any previous orthodontic treatment (braces)?

If yes, when

If yes, doctor's name and address:

Have there been any injuries to your mouth or teeth?

If yes, describe

Have you ever had any injury in the head and neck area?

If yes, describe

Have you ever fallen and bumped your chin, or received a blow to your jaws?

If yes, describe

Have you ever had any surgery in the head and neck area?

If yes, describe

Do you clench or grind your teeth?

If yes,

Other

Do your jaw muscles ever feel tired?

If yes, when

Do you ever notice soreness, tightness or pain in the muscles around the jaws and face?

If yes, describe

Does it hurt to chew?

If yes, where does it hurt?

Do you hear clicking (popping) or grating sounds in your jaw joints?

Check all that apply

When did it start and during what activity?

Did these sounds begin gradually or suddenly?

Please describe the specific event that started the joint sounds, if applicable.

Have you ever experienced difficulty in opening or closing your jaws?

If yes, describe

Have your jaws ever “locked” closed?

If yes, describe

Have your jaws ever “locked” wide open?

If yes, describe

Do you have pain in your jaw joints?

If yes, which side of your mouth? Since when?

Did your pain start gradually or suddenly?

During what activity?

Describe nature of pain

What increases/decreases the pain?

Do you have any of the following habits?

Finger/Thumb Sucking

Lip Biting

Nail Biting

Gum Chewing

Ice Chewing

Smoking or using other tobacco products

Please describe why you sought this consultation

Have you ever been treated for this problem before?

If yes, please describe the diagnosis and treatment:

Have any other members of the family had orthodontic treatment?

Have any other members of the family been patients in this office?

Names?

We recognize that patients sometimes have specific concerns that may not be addressed by the questions in this Clinical History Form. Please feel free to include any other information regarding your clinical history, or any other concerns that you may have, in the space below.

I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my responsibilty to inform this office. I also give my permission for a clinical examination.