1. About You
First Name
Last Name
Gender
Birthdate
Age
Social Security #
Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Palau
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip
Email
Home Phone
Work Phone
Who is your cell phone provider?
Employer
How Long There?
Occupation
Where & when are the best times to reach you?
General Dentist
Date of Last Dental Visit
Whom may we thank for referring you?
What are your main concerns for this appointment?
2. Spouse Information
His/Her Name
Employer
Person Responsible For Account
Home Phone
Work Phone
Address
City
State
Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Vermont
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Relation
Social Security #
Employer
3. Dental/Orthodontic Insurance
Do you have orthodontic coverage?
Yes
No
Please Choose One
Insurance Co. Name
Insurance Co. Address
Physician's Name
Insurance Co. Phone
Subscriber ID#
Relation
Insured Birthdate
Social Security #
Insured's Employer
4. Medical History
Do you have a personal physician?
Yes
No
Please Choose One
Physician's Name
Physician's Phone
Date of Last Visit
Your current physical health is:
Good
Fair
Poor
Please Choose One
Are you currently under the care of a physician?
Yes
No
Please Choose One
Are you currently using any tobacco products?
Yes
No
Please Choose One
Are you taking any prescription / over-the-counter drugs?
Yes
No
Please Choose One
If yes, please list:
Were you breastfed as a child?
Yes
No
Not Sure
Please Choose One
For Women
Are you taking birth control pills?
Yes
No
Please Choose One
Are you pregnant?
Yes
No
Please Choose One
Are you nursing?
Yes
No
Please Choose One
Have you ever had any of the following diseases or medical problems?
Anemia
Yes
No
Please Choose One
Radiation Treatment
Please Choose One
Yes
No
Artificial Bones/Joints
Yes
No
Please Choose One
Artificial Valves
Yes
No
Please Choose One
Asthma
Yes
No
Please Choose One
Arthritis
Please Choose One
Yes
No
Blood Transfusion
Yes
No
Please Choose One
Bruxism/Grinding
Yes
No
Please Choose One
Cancer/Chemotherapy
Yes
No
Please Choose One
Clenching
Yes
No
Please Choose One
Congenital Heart Defect
Yes
No
Please Choose One
Diabetes/Tuberculosis(TB)
Yes
No
Please Choose One
Difficulty Breathing
Yes
No
Please Choose One
Drug/Alcohol Abuse
Yes
No
Please Choose One
Emphysema/Glaucoma
Yes
No
Please Choose One
Epilepsy/Seizures/Fainting Spells
Yes
No
Please Choose One
Fever Blisters/Herpes
Yes
No
Please Choose One
Head and Neck Pain
Yes
No
Please Choose One
Headaches
Yes
No
Please Choose One
Heart Attack/Stroke
Yes
No
Please Choose One
Heart Murmur
Yes
No
Please Choose One
ADD
Yes
No
Please Choose One
ADHD
Please Choose One
Yes
No
Aspergers
Please Choose One
Yes
No
Heart Surgery/Pacemeaker
Yes
No
Please Choose One
Hemophilia/Abnormal Bleeding
Yes
No
Please Choose One
Hepatitis
Yes
No
Please Choose One
High Blood Pressure
Yes
No
Please Choose One
Low Blood Pressure
Please Choose One
Yes
No
HIV+/AIDS
Yes
No
Please Choose One
Hospitalized for Any Reason
Yes
No
Please Choose One
Keloid Formations
Yes
No
Please Choose One
Kidney Problems
Yes
No
Please Choose One
Mitral Valve Prolapse
Yes
No
Please Choose One
Psychiatric Problems
Yes
No
Please Choose One
Rheumatic/Scarlet Fever
Yes
No
Please Choose One
Severe/Frequent Headaches
Yes
No
Please Choose One
Shingles
Yes
No
Please Choose One
Sinus Problems
Yes
No
Please Choose One
Sleep Apnea
Yes
No
Please Choose One
Snoring
Yes
No
Please Choose One
TMJ Pain
Yes
No
Please Choose One
Ulcers/Colitis
Yes
No
Please Choose One
Venereal Disease
Yes
No
Please Choose One
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Aspirin
Yes
No
Please Choose One
Tetracycline
Any Metal/Plastic
Yes
No
Please Choose One
Codeine
Yes
No
Please Choose One
Dental Anesthetics
Yes
No
Please Choose One
Erythromycin
Yes
No
Please Choose One
Latex
Yes
No
Please Choose One
Penicillin
Yes
No
Please Choose One
Tetracycline
Yes
No
Please Choose One
Other
Yes
No
Please Choose One
Please list any other drugs that you are allergic to:
Signature of Parent or Guardian
Today's Date