Download MEDICAL HISTORY - Bellamy Orthodontics

Welcome to our practice!
Please take a minute to fill out the necessary information below. If you have any
concerns about this initial examination, please talk to one of our staff before we begin.
Patient Information
Date _______________________
Please Circle:
Male
Female
Patient’s name_____________________________________________________Date of Birth (D/M/Y)_______________
Last
First
Address_______________________________________________________________________________________________
Street
City
Postal Code
Home Phone_____________________ Alternate Phone # ___________________ Email___________________________
Dentist_________________________________
Whom may we thank for referring you to our office?_______________________________________________________
Responsible Party Information
(please leave blank if same as above)
Name________________________________________________________________________________________________
Last
First
Relationship to Patient
Mailing Address (if different from above)_________________________________________________________________
Street
City
Postal Code
Home Phone_________________________ Work Phone______________________ Cell Phone_____________________
E-Mail Address________________________________
Spouses Name________________________________________________________________________________________
Last
First
Relationship to Patient
Dental Insurance Information
Insured’s Name______________________________________
Date of Birth __________________________________
Insurance Company_________________________ Group No.____________________ ID No.______________________
Dependant No. (if applicable)_________
Do you have dual coverage?
Yes_____
No_____
If yes:
Insured’s Name______________________________________
Date of Birth __________________________________
Insurance Company_________________________ Group No.____________________ ID No.______________________
MEDICAL HISTORY
Physician ________________________________________________
Please circle Yes or No (If Yes, please fill in details)
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Are you taking any medication? _________________________________________________________
Are you allergic to any medication? _____________________________________________________
Do you have a history of a major illness? __________________________________________________
Have you had any major operations? _____________________________________________________
Have you ever been involved in a serious accident? ________________________________________
Circle any of the medical conditions below that you have had or currently have.
Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver problems
Herpes
High Blood Pressure
HIV / Aids
Kidney problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of? _________________
____________________________________________________________________________________________________
DENTAL HISTORY
Approximate date of last dental visit: ____________________ Do you have regular checkups?
Yes
No
What concerns you most about your teeth? ______________________________________________________________
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
Are you presently in any dental pain? ____________________________________________________
Have you ever experienced any unfavorable reaction to dentistry? ___________________________
Have there been any injuries to face, mouth or teeth? _______________________________________
Do your gums bleed when you brush? ____________________________________________________
Do you have any type of thumb or tongue habit? __________________________________________
Are you a mouth breather?______________________________________________________________
Have you ever seen an orthodontist? If yes, who and when? _________________________________
Has anyone in your family received orthodontic treatment? _________________________________
How did they feel about the result? ______________________________________________________
What is your attitude toward receiving orthodontic treatment? ______________________________
Are you aware of any jaw clicking or popping? ____________________________________________
Are you aware of clenching your teeth during the day? _____________________________________
Have you ever been told that you grind your teeth? ________________________________________
If the patient is under age 16, height of parents? Mom ______
Dad ______
Female Patients only:
Are you pregnant?
If a child, has her period started?
Yes
Yes
No
No
Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the
teeth, and in general dental health. I understand that my diagnostic records may be used for educational and
promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any
changes in my medical or dental history. In addition, I authorize Dr. Bellamy to perform a complete orthodontic
evaluation.
Signature: __________________________________________________________________Date: ____________________
Thank You!
The Bellamy Orthodontic Team