Fillable Printable New Patient Health History Form
Fillable Printable New Patient Health History Form
New Patient Health History Form
New Patient Health History
Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2
nd
/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2
nd
/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone:
Do you have insurance that covers orthodontics?
Yes No
If so, please name the Insurance Company:
Dental History
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? Yes No
If so, when?
What is the patient’s main orthodontic concern?
Speech problems/therapy?
Yes No
Grind or clench teeth?
Yes No
Injury to face, jaw, teeth or mouth?
Yes No
Discomfort from teeth or gums?
Yes No
Pain, tenderness or noise in either jaw?
Yes No
Frequent headaches?
Yes No
Oral Habits (thumb/finger sucking, lip/nail biting)?
Yes No
Neck/shoulder pain?
Yes No
Frequent sore throats?
Yes No
Brush teeth daily?
Yes No
Floss teeth daily?
Yes No
Fluoride treatments?
Yes No
Mouth Breathing?
Yes No
Snores during sleep?
Yes No
Requires premedication?
Yes No
Any missing or extra permanent teeth?
Yes No
Apprehensive about dental care?
Yes No
Frequently chew gum?
Yes No
If any of the above dental questions were answered “Yes,” please explain:
Medical History
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Rheumatic Fever
Yes No
Tuberculosis/Lung Disease
Yes No
Pneumonia
Yes No
Liver Disease
Yes No
Kidney Disease
Yes No
Heart Attack/Stroke
Yes No
Heart Disease
Yes No
Congenital Heart Defect
Yes No
Heart Murmur
Yes No
Hemophilia
Yes No
Hypertension/High Blood Pressure
Yes No
Prolonged Bleeding/Transfusion
Yes No
Anemia
Yes No
HIV/AIDS
Yes No
Hepatitis
Yes No
Tonsils/Adenoids Removed
Yes No
Cancer
Yes No
Family History of Cancer
Yes No
Received Radiation Treatment
Yes No
Growth Problems
Yes No
Endocrine Problems
Yes No
Hormone Therapy
Yes No
Latex/Metal Allergy
Yes No
Nervous Disorders
Yes No
Bone Disorders/Bone Loss
Yes No
Diabetes
Yes No
Seizures/Epilepsy
Yes No
Handicaps/Disabilities
Yes No
Asthma
Yes No
Arthritis
Yes No
Treated for Emotional Problems
Yes No
Ever Been Hospitalized
Yes No
If any of the above medical questions were answered “Yes,” please explain:
Patients Under 18
Please list the name and birth date of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
Yes No
If patient is a girl, has menstruation begun?
Yes No
If patient is a boy, has their voice changed or have facial hair?
Yes No
Has the patient grown in the past year or has their shoe size changed recently?
Yes No
Patient’s interest in treatment?
Has either biological parent ever had orthodontic treatment?
Yes No
Signature: ______________________________________________ Date: ________
