HEALTH FORM

Please complete the information requested in this form and press the "Submit" button at the bottom.

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Patient Information
   
Name A value is required.
Nickname
Birthdate A value is required.Invalid format.
Sex
     Male:   Female:
Marital Status
Address A value is required.
City A value is required.
State A value is required.
Zip A value is required.Invalid format.
Home Phone A value is required.Invalid format.
Work Phone Invalid format.
E-Mail Invalid format.
School/Employer
Spouse's Name
Responsible Party Information
   
Name
Relationship to Patient
Address (if different)
City
State
Zip
Birthdate
Marital Status
Home Phone
Work Phone
E-Mail
Employer
SS Number A value is required.Invalid format.
Dental Insurance Co.
    If minor, patient lives with
    Interests / Hobbies
    Whom may we thank for referring you?

   
Information for Patients Who Are Minors
           
    Mother's Name Father's Name
    Birthdate Invalid format. Birthdate Invalid format.
    Marital Status Marital Satus
    Address (if different) Address (if different)
    City City
    State State
    Zip Invalid format. Zip Invalid format.
    Home Phone Invalid format. Home Phone Invalid format.
    Work Phone Invalid format. Work Phone Invalid format.
    E-Mail Address Invalid format. E-Mail Address Invalid format.
    Employer Employer
    Position Position
    Social Security Number Invalid format. Social Security Number Invalid format.
           
  Medical and Dental History
  General Dentist      Physician  
  Present Health     Good       Fair       Poor
  Specific drugs or medications currently taken
 
   
  Has patient been under the care of a physician during the past 2 years other than for routine examinations? 
 Yes    No
 
Please specify  
  Has patient received treatment from an allergist or ear, nose, and throat (ENT) specialist?
    Yes    No    If yes, when?  
  Has patient had tonsils and/or adenoids removed?  Yes   No
     If Yes, When?
    Has patient ever had any of the following conditions?  
    AIDS Epilepsy Allergies to:
    Arteriosclerosis Endocrine Problems    Antiobiotics
    Asthma Emotional Problems    Pain Pills
    Autoimmune disorder Female Problems    Dairy Products
    Blood Diseases Hepatitis    Wheat, cereal
    High Blood Pressure Heart Disease    Food dyes
    Low Blood Pressure Hearing Disorder    Latex
    Bone Disorders Kidney Disease    Dust, pollen
    Cancer Rheumatic Fever    Animals
    Diabetes Sleep disturbance    Other:
    Dizziness Trauma to face, jaws, or head    Other:
    Dyslexia, ADD Tuberculosis  
    Other learning disability (please specify)
         
    Birth defects (please specify)
         
  Please indicate all descriptions that apply to the patient
  Jaw has "locked" open or closed Headaches
  Snores when sleeping Speech problems
  Breathes through mouth more than nose Sucking habits (thumb, finger, lip, etc.)
  Frequent Colds, sore throats, or tonsilitis Grinds or clenches teeth
  Difficulty chewing and/or swallowing Smokes
  Pain and/or clicking in jaw joint Previous orthodontic consultation
  Permanent teeth erupt behind baby teeth Previous orthodontic appointment
  Teeth removed by a dentist Unusual dental experience
  Facial cosmetic dentistry        Please specify
        
  Please describe any medical, dental or surgical problems not covered above
 
  Names and ages of siblings if patient is a minor
 
     
  Family members with similar orthodontic condition
  Mother    Father    Brother    Sister    Grandmother    Grandfather    Other