Patient Information. Patient s First and Last name: Preferred Name: Mailing Address: City: State: Zip Code: Date of Birth: Gender:

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1 Patient Information: Patient Information Patient s First and Last name: Preferred Name: Mailing Address: Date of Birth: Gender: Best Number to Confirm Your Appointments: Alternate Phone Number: Social Security Number: Are You a Student? YES NO If so, What School Do You Attend? Address: Dentist Date of Last Visit: Physician Date of Last Visit: Are You Related to Any Patients We Are Currently Seeing: YES NO If so, Who: Who may we thank for referring you?_ Billing Party: First and Last Name: Relationship To The Patient: Billing Address: Phone Number: SSN: Spouse: Date of Birth: Employer: Marital Status:

2 As a courtesy to our patients we will be happy to file insurance claims on your behalf. We can provide pre authorizations if needed and are working to help you maximize your insurance benefits. To have claims processed in a timely manner we do need a copy of your dental insurance card and the following information filled out completely. Insurance Information: Do you have dental insurance? YES NO Insurance Company Name: Policy ID Number: Group Number: Effective Date: Is it an Employer Plan? YES NO Employer Name: Employer Address: City State: Zip Code: Employer Phone Number: Subscriber First and Last Name: Relationship to patient Date of Birth: SSN: Address (if different from billing party): Phone Number:

3 Check the box if you have, or if you have ever had, any of the following: Birth Defects or hereditary problems Bone fractures, any major accidents Rheumatoid or arthritic conditions Endocrine or thyroid problems Kidney Problems Diabetes Cancer, tumor, radiation treatment or chemotherapy Stomach ulcer or hyperacidity Polio, mononucleosis, tuberculosis, pneumonia Problems of the immune system AIDS or HIV positive Hepatitis, jaundice, or liver problems Fainting spells, seizures, epilepsy or neurological problems Mental health disturbance or depression Vision, hearing, tasting, or speech difficulties Rapid weight loss, poor appetite History of eating disorder (anorexia, bulimia) Excessive bleeding or bruising tendency, anemia or bleeding disorder High or low blood pressure Tired Easily Chest Pain, shortness of breath or swelling ankles Cardiovascular problems (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease) Skin disorder Frequent headaches, colds or sore throats Eye, ear, nose, or throat condition Hayfever, asthma, sinus trouble or hives Tonsil or adenoid conditions Osteoporosis A substance abuse problem Do you chew or smoke tobacco Women Only: Are you pregnant Are you currently taking birth control Allergies or reactions to any of the following: Metals (Jewelry, clothing snaps) Latex (Gloves, balloons) Vinyl Acrylic Other Substances (specify) Are you taking medication, dietary supplements, herbal medications or non prescription medicine? If so please list:

4 Dental History: Check the box if you have, or if you have ever had, any of the following: Permanent or extra (supernumerary) teeth Supernumerary (extra) or congenitally missing removed teeth Teeth sensitive to hot or cold; teeth throb or ache Dead teeth or root canals treated Periodontal gum problems Gum Boils, frequent canker sores or cold sores Abnormal swallowing habit (tongue thrusting) Mouth breathing habit, snoring or difficulty in breathing Any pain, clicking, locking in jaw or ringing in the ears Local anesthetics (Novocaine or Lidocaine) Aware of any loose, broken or missing restorations (fillings) Jaw fractures, cysts or mouth infections Bleeding gums, bad taste or mouth odor Food impaction between teeth Thumb, finger or sucking habit Until what age History of speech problems Tooth Grinding or Jaw Clenching Difficulty in chewing or jaw opening Have you ever been treated for TMD or TMJ Any teeth irritating cheek, lip, tongue or palate Concerned about spaced, crooked or protruding teeth Any relatives with similar tooth or jaw relationships Had periodontal (gum) treatment Been under another dentist s care Specialist Other Aware or concerned about under or over developed jaw Any wisdom tooth problems Had any serious trouble associated with any previous dental treatment Ever had a prior orthodontic examination or treatment Would you object to wearing orthodontic appliances (braces) should they indicated YES NO How often do you brush: floss: What is your primary concern? Why are you here? I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice. Signed: Date Signed: (Patient)

5 What is your name? Who is your favorite sports team or player? Do you play sports, what position? What are some of your favorite things to do? What is your favorite food? What is your favorite book and author? Where is your favorite place to go on vacation? Where would you like to go someday? Do you have Pets, what kind, what are their names? Who is your Hero? Who is your best friend? Do you have any brother or sisters? What are their names and ages? What is a funny story about you?

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