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New Patient Health and History Questionnaire
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* Indicates required question
Patient's Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Gender
*
Female
Male
Patient's Mailing Address (Include City, State, Zip)
*
Your answer
Patient's Cell Phone
*
Your answer
Cell Phone Provider for text reminders (ie...Sprint, AT&T, Verizon)
*
Your answer
Patient's School (if applicable)
Your answer
Patient's Grade (if applicable)
Your answer
Hobbies or Interests
*
Your answer
Patient's Insurance Company
Your answer
Primary Insured Name
Your answer
Primary Insured Date of Birth
MM
/
DD
/
YYYY
Primary Insured Social Security or ID#
Your answer
Patient's Secondary Insurance Company
Your answer
Secondary Insured Name
Your answer
Secondary Insured Date of Birth
MM
/
DD
/
YYYY
Secondary Insured Social Security or ID#
Your answer
Parent/Guardian Name
Your answer
Relationship to Patient
Your answer
Mailing Address (Include City, State, Zip)
Your answer
Cell Phone
Your answer
Cell Phone Provider for text reminders (ie...Sprint, AT&T, Verizon)
Your answer
Email Address
Your answer
Secondary Parent/Guardian Name
Your answer
Relationship to Patient
Your answer
Mailing Address (Include City, State, Zip)
Your answer
Cell Phone
Your answer
Cell Phone Provider for text reminders (ie...Sprint, AT&T, Verizon)
Your answer
Email Address
Your answer
Patient Health History (please check all that apply)
*
AIDS/HIV
Allergies
Asthma
Chronic Neck Pain
Clicking of the Jaw
Cold Sores/Herpes
Endocrine Problems
Emotional Disorders
Headaches
Heart Condition
Hepatitis
High Blood Pressure
Latex Allergy
Mouth Breathing
Periodontal (Gum) Problems
Seizures
Speech Problems
TMJ (Jaw) Problems
Tooth Grinding
Tuberculosis
None of the Above
Required
Any disease, problems or allergies not listed above
Your answer
List current medications
Your answer
For women only: Is there any condition that would restrict you from having x-rays
Yes
No
Clear selection
Have you had previous orthodontic treatment
*
Yes
No
Have you had a previous orthodontic consultation
*
Yes
No
If you answered yes to one of the last two questions, please provide the location
Your answer
Names and ages of siblings (children only)
Your answer
Current Dentist and Location
*
Your answer
Estimate of last visit
*
Your answer
Do you have any unfinished dental work
*
Yes
No
Release of Information: I authorize the release of information, including diagnosis, records, appointment information, financial information and insurance information. This information may be released to the following people only:
*
Your answer
If we need to call or leave a message we may do so on the following:
*
My home
My work
My cell phone
You may leave a detailed message
Please leave a message asking me to return your call only
Required
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