ACQUAINTANCE/HEALTH QUESTIONNAIRE

Welcome to our office!

The following information is requested to enable us to give you the best possible evaluation during your initial examination in our office. In order for us to thoroughly diagnose any condition, we must have accurate background and health inforamtion on which to base our decisions. This information, important for our records and your health, is confidential. Thank you.

Patient Information

Date: Age:
Last Name: First name:
Street Address: City:
Middle Initial: Nickname:
State: Zip Code:
Home Phone: Birthdate:
Social Security # Names of any family members that have visited us before:
Whom may we thank for referring you? Dentist's Name:
How did you hear of our office?

Responsible Party Information

Last Name: First Name:
Middle Name: Marital Status:
Residence      
Street: City:
State: Zip Code:
Mailing Address      
Street: City:
State: Zip Code:
How Long at this address? Home Phone:
Work Phone: Cell Phone:
Email Address: Fax:
Previous Address: (if less than three years)    
Street: City:
State: Zip Code:
Social Security # Relationship to Patient:
Employer: Occupation:
No. of years employed: Birthdate:
Spouse:      
Last Name: First Name:
Middle Name: Relationship to Patient:
Employer: Occupation:
Years Employed: Social Security#:
Cell Phone: Work Phone:
Birthdate: Email Address:

Orthodontic Insurance Information

Insured's Name Insured's Soc.Sec#
Insurance Company Group No.
Payroll No. Insurance Co. Adderss
Insured's Employer
Insurance Co Phone:    
Do you have dual coverage?    
Insured's Name: Insured's Soc.Sec#:
Insurance Company : Group No.:
Payroll No.#: Insurance Company Address:
Insurance Co. Phone: Employer:
       

Emergency Information

Name of nearest relative not living with you: Complete Address:
Phone:    

Medical History

Please circle any of the following that apply to the patient now or in the past:

R
L
       
Are you under the care of a physician for a specific problem?

Dental/Medical Related History

Please indicate any of the following that apply:
Clenching or grinding teeth
Frequent Headaches Jaw tiredness upon awakening
Neck Injury Frequent Ear Pain
Jaw Locking Open Back Injury
Have you ever been diagnosed and/or treated for temporomandibular joint (TMJ) disorders?
If so, when? Treated by whom?

Dental History

Dentist (name and city):
Dental Check-ups:
Date of last check-up: Have all recommended dental procedures been completed?
Have you ever been diagnosed and/or treated for gum disease? If so, when?
Please list any dental problems we should know about:
Have you received an evaluation or treatment in another orthodontic practice?
If so, orthodontist's name and city?
Whom may we thank for referring you?
   
I understand that where appropriate credit bureau reports may be obtained: Yes No
Can we send you emails with information and events from our office? Yes

Human Verification

Please enter the verification codes listed below to continue with submitting your form.