Patient Health History Form

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Save Print Form" at the bottom.


Patient Information


Items marked with asterisk (*) must be completed.
First Name*
Middle Name
Last Name*
I prefer to be called (Nickname)
Address*
Street
City
State/Province
Zip/Postal Code
Country
Home Phone*--
Work Phone--
Cell/Other Phone--
Email Address
Birthdate (MM-DD-YYYY)*--
Gender
Social Security Number (adults only)--
If patient is a minor, give parent's or guardian's name
Whom may we thank for referring you to our office?

Responsible Party Information
Full Name
Residence
Street
City
State/Province
Zip/Postal Code
Country
Mailing Address
Street
City
State/Province
Zip/Postal Code
Country
How long at this address?years
Own or Rent?
Home Phone--
Work Phone--
Cell/Other Phone--
Email Address


If patient is under 18, please complete this section.
Previous Address
Street
City
State/Province
Zip/Postal Code
Country
if less than 3 years
Social Security Number (U.S. only)--
Birthdate--
Relationship to Patient
Employed, Retired, Other?
Employer
Occupation
Number of Years at Current Employer
Spouse's Name
Relationship to Patient
Employed, Retired, Other?
Employer
Number of Years at Current Employer
Occupation
Social Security Number (U.S. only)--
Birthdate--
Home Phone--
Work Phone--
Cell/Other Phone--
Email Address

Medical Insurance Information
Insured's Name
Relationship to Patient
Insured's Social Security Number (U.S. only)--
Insured's Date of Birth--
Insurance Company
Group Number
Local Number
Employer's Name
Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
Phone Number--
Do you have dual coverage?
Insured's Name
Relationship to Patient
Insured's Social Security Number (U.S. only)--
Insured's Date of Birth--
Insurance Company
Group Number
Local Number
Insurance Company Address
Street
City
State/Province
Zip/Postal Code
Country
Phone Number--

Emergency Information
Name of the nearest relative not living with you
Complete Address
Street
City
State/Province
Zip/Postal Code
Country

Medical History
 

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Physician
Date of Last Visit--
Address
Street
City
State/Province
Zip/Postal Code
Country
Phone--


Please check any of the following which apply to you, and add any relevant comments.
Do you have a history of any major illness?
Are you taking any medication?
Have you had any major operations?
Have you ever been involved in a serious accident?
Female patients: Are you pregnant?
Are you currently under the care of a physician?


Please check any of the following that you have had or currently have:
Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History
Family Dentist
Date of Last Visit--
What would you like orthodontics to accomplish?


Please check any of the following which apply to you, and add any relevant comments.
Comment:
Comment:
Comment:
Comment:
Comment:
Comment:
How does the patient relate to new experiences?
Comment:
We would like to make your visit as comfortable as possible, so if there is anything else you would like to add regarding you or your child, please feel free to note them here or inform us at any time: