CONFIDENTIAL PATIENT INFORMATION
Date
Patient's First Name
Patient's Last Name
Middle
Nickname
Birthdate
Age
Social Security #
Gender
Address
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zipcode
Home Phone
Cell Phone
School
Grade
Patient's Physician
Phone Number
Date of Last Exam
Dentist
Last Cleaning
Favorite Spots/Hobbies
Whom may we thank for referring you to our office?
RESPONSIBLE PARTY INFORMATION
First Name
Last Name
Middle
Email Address
Mother/Father/Other
Marital Status
residence address
city
state
zipcode
Residential Type
Own
Rent
mailing address
city
state
zipcode
Relation to Patient
Home Phone
Cell Phone
Work Phone
Social Security #
Birthdate
Employer
Occupation
Years Employed
Spouse's First Name
Spouse's Last Name
Spouse's Middle Name
Relationship to Patient
Home Phone
Cell Phone
Work Phone
Social Security #
Birthdate
Employer
Occupation
Years Employed
INSURANCE INFORMATION
Primary Dental Insurance
Policy Holder
Birthdate
Insurance Company Address
Phone Number
Policy ID (or SS#)
Group #
Employer
Secondary Dental Insurance
Policy Holder
Birthdate
Insurance Company Address
Phone Number
Policy ID (or SS#)
Group #
Employer
EMERGENCY CONTACT
Contact Name
Phone
Complete Address
Relation
HEALTH HISTORY
Have you had a history of any of the following?
ADHD / ADD
Yes
No
Cleft Lip / Palate
Yes
No
Kidney Disease
Yes
No
Allergies
Yes
No
Depression
Yes
No
Learning Disability
Yes
No
Anemia
Yes
No
Diabetes
Yes
No
Liver Disease
Yes
No
Asthma
Yes
No
Dizziness / Fainting
Yes
No
Premature Birth
Yes
No
Autism
Yes
No
Epilepsy
Yes
No
Rheumatic Fever
Yes
No
Behavioral Disorders
Yes
No
GERD / Reflux
Yes
No
Seizures
Yes
No
Bleeding / Transfusion
Yes
No
HIV / AIDS
Yes
No
Snoring / Noisy Breathing While Sleeping
Yes
No
Bleeding Disorders
Yes
No
Heart Disease
Yes
No
Speech / Hearing Problems
Yes
No
Cancer / Tumors
Yes
No
Hepatitis
Yes
No
Cerebral Palsy
Yes
No
Hospitalizations
Yes
No
If you answered yes, or there are other problems, please explain:
Is the patient under the care of a physician for a specific condition not listed above?
Yes
No
If yes, please describe
Is the patient taking any medications?
Yes
No
If yes, please list medication and what it's taken for
Is the patient up-to-date on their required immunizations?
Yes
No
Has the patient ever been hospitalized or had treatment under general anesthesia?
Yes
No
Has the patient ever had a visit to the emergency room?
Yes
No
Do you consider the patient to be
Advanced in the learning process
Progressing normally
Slow in the learning process
Has the patient ever received serious trauma or injury to the teeth, face, jaws or head?
Yes
No
If YES please explain:
Has the patient ever experienced an adverse reaction during a medical or dental procedure?
Yes
No
If YES please explain:
Does the patient have pain with chewing, yawning, or wide opening?
Yes
No
Does the patient’s jaw make noise and is pain associated with the sounds?
Yes
No
Does the patient grind their teeth?
Yes
No
Does the patient have any speech problems/tongue thrust?
Yes
No
Does the patient have, or ever had, any pacifier, thumb or finger sucking habits?
Yes
No
Does the patient have a family history of jaw size imbalance or missing, impacted, malformed or extra teeth?
Yes
No
Has the patient been treated for or diagnosed with any periodontal problems?
Yes
No
FLOURIDE HISTORY
Is your drinking water fluoridated?
Yes
No
Do you use well water in your home?
Yes
No
If yes, has it been analyzed for flouride?
Yes
No
Does the patient use a flouride toothpaste?
Yes
No
Does the patient use any other form of fluroide?
Yes
No
If YES, what?
ORTHODONTIC HISTORY
For Patients Age 7 & Older
In your words, what is the orthodontic problem?
Has the patient had any previous orthodontic treatment or consultation?
Yes
No
If yes, what was completed, and by whom?
Have any other family member(s) had orthodontic treatment?
Please best describe the patient's attitude toward orthodontic treatment
Wants treatment
Treatment is necessary
Unwilling, but agrees
Uncooperative
GROWTH & DEVELOPMENT DATA
Girls: Has the patient's menstruation started?
Yes
No
If YES, what age
Boys: Has the patient’s voice changed?
Yes
No
Is the patient still actively growing?
Yes
No
AUTHORIZATION
I agree that I have received and reviewed the Financial Responsibility Form
Yes
No
I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the orthodontist and pediatric dentist to help determine appropriate and helpful treatment. I also understand that if there is any change to my, or the above named patient’s dental or medical status, it is my responsibility to inform the doctor.
By providing a mobile number, I agree that Carolina Orthodontics & Children’s Dentistry may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.
SIGNATURE OF PATIENT
date
Submit
