Download Patient Registration - Sparkman Orthodontics

Patient Registration
Please enter the patient's details
First Name
Middle Name
Optional
Last Name
Family name
Preferred Name
Nickname
Birth Date
MM/DD/YYYY
Gender Female
Of Patient
Marital Status Single
Male
Married
Divorced
Address
The first line of your address
City
City or town
State
State or county
Zip
Zip or postcode
Home Phone
Please include area code
Work Phone - Ext
Please include extension if applicable
Cell Phone
Email
Valid addresses only
Dentist
Name of your dentist
Dental Visit
Date of your last visit MM/DD/YYYY
Referred by
Who may we thank for referring you to
our office?
1/4
Orthodontic Treatment
Have you ever had orthodontic
treatment?
Yes
No
Yes
No
Family
Have any member of your family had
orthodontic treatment?
Family
Names of previously treated family
What do you want to
accomplish with
orthodontic treatment?
Patient's attitude toward
orthodontic treatment?
Sports/Hobbies
School (if applicable)
School Name
Address
The first line of the address
City
City or town
State
State or county
Zip
Zip or postcode
Responsible Party
If the patient has a responsible party, please enter their details
First Name
Middle Name
Optional
Last Name
Family Name
Birth Date
MM/DD/YYYY
SSN
Social Security Number
2/4
Sex
Gender
Marital Status
Male
Female
Single
Married
Divorced
Home Phone
Please include your area code
Work Phone
Please include extension if applicable
Cell Phone
Address
The first line of your address
City
City or town
State
State or county
Zip
Zip or postcode
Relation to Patient
Email
Valid addresses only
Second Responsible Party
If the patient has a responsible party, please enter their details
First Name
Middle Name
Optional
Last Name
Family Name
Birth Date
MM/DD/YYYY
SSN
Social Security Number
Sex
Gender
Marital Status
Female
Single
Male
Married
Divorced
Home Phone
Please include your area code
Work Phone
Please include extension if applicable
3/4
Cell Phone
Address
The first line of your address
City
City or town
State
State or county
Zip
Zip or postcode
Relation to Patient
Email
Valid addresses only
Emergency Information
Please enter emergency contact information
Name
Name of nearest relative not living
with you
Address
Complete mailing address
Phone
Including area code
Relationship
Responsible Party Signature
4/4
Health History
Medical History - please answer if patient has, or has not had the following:
Latex Allergy? Yes
No
List any other allergies:
Joint swelling or Arthritis? Yes
Bone Disorders? Yes
No
No
Heart Trouble? Yes
No
Mitral Valve Prolapse? Yes
Rheumatic Fever? Yes
Diabetes? Yes
No
No
No
Hepatitis or Liver Problems? Yes
Emotional Problems? Yes
Brain Injury? Yes
No
No
Kidney Problems? Yes
No
Joint Prosthesis? Yes
No
Tuberculosis? Yes
Anemia? Yes
No
No
No
Epilepsy (Convulsions)? Yes
Prolonged Bleeding? Yes
No
No
Faintness/Dizziness/Ringing in ears? Yes
Tonsil(s) Removed? Yes
No
When:
Adenoids Removed? Yes
No
When:
Sore Throat? Yes
No
Tonsillitis? Yes
No
Earaches? Yes
No
AIDS or HIV? Yes
Asthma? Yes
No
No
Endocrine Problems? Yes
Pneumonia? Yes
No
No
Nervous Disorders? Yes
No
No
High Blood Pressure? Yes
Hearing Disorder? Yes
Major/Minor Surgery? Yes
Type/Date:
No
No
No
Has patient reached puberty (girl - started menstruation, boy - has his voice changed)?
Yes
No
List any serious illnesses:
Please list all medications, over the counter and herbal supplements that you take:
Have any members of your family had:
Rheumatoid Arthritis? Yes
Lupus? Yes
No
No
Dental History - please answer if patient has, or has had the following:
Any injuries to face, mouth or teeth? Yes
Thumb, finger or lip sucking? Yes
No
No
More than average amount of tooth decay? Yes
Missing permanent teeth? Yes
Extra permanent teeth? Yes
No
No
Teeth removing by extraction? Yes
No
Difficulty in swallowing or chewing? Yes
Tongue thrust problem? Yes
No
No
No
Mouth breathing when asleep? Yes
No
Mouth breathing when awake? Yes
No
Pain or clicking when opening mouth? Yes
Clenching or grinding of teeth? Yes
No
No
Frequent headaches? Yes
No
Headaches per week/time of day:
Muscle tenderness or stiffness in the jaw or neck? Yes
Patient/Responsible Party
No
Date