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717-262-4002
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Forms Test

1 Patient Information

2 Medical Information

3 General Information

4 Insurance Information

5 Medical History

6 Dental History

7 Patient Health Information

8 Release & Waiver

Patient
Patient's Name*
Prefix First Middle Last
I prefer to be called:
Birth Date*
MM
DD
YYYY
Sex
- Male
- Female
- Non-binary
Marital Status
- Single
- Married
- Separated
- Divorced
- Widow
Home Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email Address*
Occupation
Employer
Closest Relative
Spouse or closest relatives name(s)*
Title
Prefix
Relationship to Patient*
Address
(if different from patient address)

Street Address Address Line 2 City State ZIP Code
Home Phone
(if different)
Cell Phone
Work Phone

Dentist
Patient's Dentist*
Address
Street Address Address Line 2 City State ZIP Code
Last Seen*
MM
DD
YYYY
Reason*
Next Appointment
MM
DD
YYYY
Other dentists/dental specialists now being seen
Address
City State
Reason
Physician
Patient's Physician*
Address
City State
Last Seen*
MM
DD
YYYY
Reason*
Next Appointment
MM
DD
YYYY
Most recent physical exam
Other physicians/health care provides being seen now:
Click the plus icon to add additional rows
Name City, State Reason

General Information
What concerns you about your teeth?
Who suggested you might need orthodontic treatment?
Why did you select our office?
If you've had any previous orthodontic treatment, please describe.
If any other family members have been treated in this office, please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account?*
Address
(if different from patient address)

Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Email Address*
Employer*

Dental Insurance
Primary policy holder's full name*
First Middle Last
Birth Date*
MM
DD
YYYY
Relationship to patient*
Address
(if not listed previously)

Street Address Address Line 2 City State ZIP Code
Phone*
Employer*
Employer Address
Street Address City State ZIP Code
Insurance Company*
Group #*
ID#*
Does this policy have orthodontic benefits?*
- Yes
- No
- Don't Know
Secondary policy holder's full name
First Middle Last
Birth Date
MM
DD
YYYY
Relationship to patient
Address
(if not listed previously)

Street Address Address Line 2 City State ZIP Code
Phone
Employer
Employer Address
Street Address City State ZIP Code
Insurance Company
Group #
ID#
Does this policy have orthodontic benefits?
- Yes
- No
- Don't Know

Medical History
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

For the following questions, please mark yes, no, or don't know/understand (dk/u).
Now or in the past, have you had:
Birth defects or hereditary problems?*
- Yes
- No
- DK/U
Please explain*
Bone fractures or major injuries?*
- Yes
- No
- DK/U
Please explain*
Any injuries to face, head, neck?*
- Yes
- No
- DK/U
Please explain*
Arthritis or join problems?*
- Yes
- No
- DK/U
Please explain*
Endocrine or thyroid problems?*
- Yes
- No
- DK/U
Please explain*
Diabetes or low sugar?*
- Yes
- No
- DK/U
Please explain*
Kidney problems?*
- Yes
- No
- DK/U
Please explain*
Cancer, tumor, radiation treatment or chemotherapy?*
- Yes
- No
- DK/U
Please explain*
Stomach ulcer, hyperacidity, acid reflux?*
- Yes
- No
- DK/U
Please explain*
Immune system problems?*
- Yes
- No
- DK/U
Please explain*
ADD/ADHD?*
- Yes
- No
- DK/U
Please explain*
History of osteoprosis?*
- Yes
- No
- DK/U
Please explain*
Gonorrhea, syphillis, herpes, sexually transmitted diseases?*
- Yes
- No
- DK/U
Please explain*
AIDS or HIV positive?*
- Yes
- No
- DK/U
Please explain*
Hepatitis, jaundice, or other liver problems?*
- Yes
- No
- DK/U
Please explain*
Polio, mononucleosis, tuberculosis, pneumonia?*
- Yes
- No
- DK/U
Please explain*
Seizures, fainting spells, neurologic problems?*
- Yes
- No
- DK/U
Please explain*
Mental health disturbance or depression?*
- Yes
- No
- DK/U
Please explain*
Vision, hearing, or speech problems?*
- Yes
- No
- DK/U
Please explain*
History of eating disorder (anorexia, bulimia)?*
- Yes
- No
- DK/U
Please explain*
High or low blood pressure?*
- Yes
- No
- DK/U
Please explain*
Excessive bleeding or bruising, anemia?*
- Yes
- No
- DK/U
Please explain*
Chest pain, shortness of breath, tire easily, swollen ankles?*
- Yes
- No
- DK/U
Please explain*
Heart defects, heart murmur, rheumatic heart disease?*
- Yes
- No
- DK/U
Please explain*
Angina, arteriosclerosis, stroke or heart attack?*
- Yes
- No
- DK/U
Please explain*
Skin disorder (other than common acne)?*
- Yes
- No
- DK/U
Please explain*
Do you eat a well-balanced diet?*
- Yes
- No
- DK/U
Please explain*
Frequent headaches or migraines?*
- Yes
- No
- DK/U
Please explain*
Frequent ear infections, colds, throat infections?*
- Yes
- No
- DK/U
Please explain*
Asthma, sinus problems, hayfever?*
- Yes
- No
- DK/U
Please explain*
Tonsil or adenoid condition?*
- Yes
- No
- DK/U
Please explain*
Do you frequently breath through your mouth?*
- Yes
- No
- DK/U
Please explain*
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)*
- Yes
- No
- DK/U
Please explain*
Latex (gloves, balloons)*
- Yes
- No
- DK/U
Please explain*
Aspirin*
- Yes
- No
- DK/U
Please explain*
Metals (jewelry, clothing snaps)*
- Yes
- No
- DK/U
Please explain*
Penicillin*
- Yes
- No
- DK/U
Please explain*
Other antibiotics*
- Yes
- No
- DK/U
Please explain*
Ibuprofen (Motrin, Advil)*
- Yes
- No
- DK/U
Please explain*
Acrylics*
- Yes
- No
- DK/U
Please explain*
Plant pollens*
- Yes
- No
- DK/U
Please explain*
Animals*
- Yes
- No
- DK/U
Please explain*
Foods*
- Yes
- No
- DK/U
Please explain*
Other substances*
- Yes
- No
- DK/U
Please explain*

Dental History
Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?*
- Yes
- No
- DK/U
Please explain*
Supernumerary (extra) or congenitally missing teeth?*
- Yes
- No
- DK/U
Please explain*
Chipped or injured primary or permanent teeth?*
- Yes
- No
- DK/U
Please explain*
Any sensitive or sore teeth?*
- Yes
- No
- DK/U
Please explain*
Bleeding gums, bad taste or mouth odor?*
- Yes
- No
- DK/U
Please explain*
Jaw fractures, cysts, infections?*
- Yes
- No
- DK/U
Please explain*
Any teeth treated with root canals or pulpotomies?*
- Yes
- No
- DK/U
Please explain*
"Gum boils", frequent canker sores or cold sores?*
- Yes
- No
- DK/U
Please explain*
History of speech problems or speech therapy?*
- Yes
- No
- DK/U
Please explain*
Difficult breathing through nose?*
- Yes
- No
- DK/U
Please explain*
Food impaction between the teeth?*
- Yes
- No
- DK/U
Please explain*
Mouth breathing habit or snoring at night?*
- Yes
- No
- DK/U
Frequent oral habits (sucking finger, chewing pen, etc.)?*
- Yes
- No
- DK/U
Please explain*
Teeth causing irritation to lip, cheek or gums?*
- Yes
- No
- DK/U
Please explain*
Abnormal swallowing (tongue thrust)?*
- Yes
- No
- DK/U
Please explain*
Tooth grinding or clenching?*
- Yes
- No
- DK/U
Please explain*
Clicking, locking in jaw joints?*
- Yes
- No
- DK/U
Please explain*
Soreness in jaw muscles or face muscles?*
- Yes
- No
- DK/U
Please explain*
Ringing in ears, difficulty in chewing or opening jaw?*
- Yes
- No
- DK/U
Please explain*
Have you ever been treated for "TMJ" or "TMD" problems?*
- Yes
- No
- DK/U
Please explain*
Any broken or missing fillings?*
- Yes
- No
- DK/U
Please explain*
Any serious trouble associated with previous dental treatment?*
- Yes
- No
- DK/U
Please explain*
Have you ever been diagnosed with gum disease or pyorrhea?*
- Yes
- No
- DK/U
Please explain*
Have you ever had an orthodontic consultation or treatment before now?*
- Yes
- No
- DK/U
Please explain*

Patient Health Information
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
List current medications
Click the plus icon to add more rows.
Medication Taken for
Have you ever taken intravenous bisphosphonates such as Zometa (solendromic acid, Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?*
- Yes
- No
Please explain*
Have you ever taken oral bisphosphonates such as Fosamax alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?*
- Yes
- No
Please explain*
Have you ever taken any medications to strengthen your bones?*
- Yes
- No
Please explain*
Do you or have you ever had a substance abuse problem?*
Do you chew or smoke tobacco?*
Have you noticed any changes in your face or jaws?*
Any other physical problems?*
How often do you brush?*
How often do you floss?*
Women: are you pregnant?
- Yes
- No
Women: are you trying to become pregnant?
- Yes
- No
Family Medical History
Have your parents or siblings have ever had any of the following health problems?
Bleeding disorders*
- Yes
- No
- DK/U
Please explain*
Diabetes*
- Yes
- No
- DK/U
Please explain*
Arthritis*
- Yes
- No
- DK/U
Please explain*
Severe allergies*
- Yes
- No
- DK/U
Please explain*
Unusual dental problems*
- Yes
- No
- DK/U
Please explain*
Jaw size imbalance*
- Yes
- No
- DK/U
Please explain*
Other family medical conditions?

Release & Waiver
Release of information*
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Please read carefully*
I have read the above questions and understand them. I will not hold my orthondotist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

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We love feedback!

Message*
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X

Schedule an appointment

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Name*
Email*
Phone*

Suggested Day*
Date Format: MM slash DD slash YYYY
Suggested Time*