Download DOC - Rawlins Orthodontics

Patient Information
(Please fill out this form prior to your appointment.)
Date: ___________________
Name: _________________________________________________________________ Soc. Sec. #_________________________________
Nickname: _____________________ Sex:_________
Date of Birth:_________________
Age:________
Address:___________________________________________________________________________________________________________
Patient Work Phone: ______________________ If a minor, give parent’s or guardian’s name: ______________________
Home Phone: ___________________________ Cell: ____________________________________
Email address: ______________________________ Whom may we thank for referring you? __________________________
General Dentist: ________________________________________ Physician: __________________________________
Reason for Consultation __________________________________________________________________________________________
Have you ever been examined by an orthodontist? Yes No If yes, when? _________ Had Braces? Yes No
Siblings’ names & ages: ____________________________________________________________________________________________
Any family members had orthodontics? ___________________ Where? _____________________________________________
School: ________________________________ Grade: ____________ Interests: _____________________________________________
Medical Information
Is patient in good health? .........................................................................................................Yes No
Does the patient have any history of major illness? .........................................................Yes No
Has patient ever been under the care of a physician for illness? ..................................Yes No
If yes, give reason: ________________________________________________________________________________________________
Has puberty been reached (menstruation or voice change)? _____________________________________________________
Check any of the following for which the patient has been treated or diagnosed with:
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Heart Complications
High Blood Pressure
Low Blood Pressure
Rheumatic Fever
Arthritis /
Rheumatism
Kidney Complications
Ulcers
Diabetes
Thyroid Problems
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Emphysema
Tuberculosis
Asthma
Latex Sensitivity
Allergies
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Sinus Trouble
Cancer
Hepatitis A (Infectious)
Hepatitis B (Serum)
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Venereal Disease
A.I.D.S.
H.I.V. Positive
Blood Transfusion
Hemophilia/
Prolonged Bleeding
Neurological Disorders
Epilepsy or Seizures
Fainting/Dizzy Spells
Nervous/Anxious
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Pneumonia
Bone Disorders
Herpes/Cold Sores
Anemia
Psychiatric/
Psychological Care
Periodontal Disease
Endocrine Problems
Liver Involvement
Hypoglycemia
Does patient take any bisphosphonate medications for osteoporosis, such as Fosamax? _________________________
Does the patient have a tendency to colds? Yes No Sore Throats? Yes No
Have tonsils and/or adenoids been removed? Yes No
Ear Infections? Yes No
At what age? __________________
List any drugs or medications now being taken and give reasons: _______________________________________________
____________________________________________________________________________________________________________________
List any allergies or drug sensitivity: ____________________________________________________________________________
Dental History
Have you had any injuries to the face, mouth or teeth? ....................................................Yes No
Habits:
Thumb or finger sucking..............................................................................Yes No
Mouth Breathing ...........................................................................................Yes No
Nail/Lip Biting ..............................................................................................Yes No
Grinding or Clenching of Teeth...................................................................Yes No
Tongue Thrusting...........................................................................................Yes No
Have you been informed of any missing or extra permanent teeth? .............................Yes No
-Over Please-
Financially responsible Party Information
Name: Ms. Mrs. Miss. Mr. Dr. ______________________________________________________________________
Married
Single
Separated
Divorced
Widowed
Residence: _________________________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________________________
How long at this address: _____ Home Phone: _______________Cell: ________________Work Phone: _________________
Previous Address (if less than 3 years): ___________________________________________________________________________
Social Security# _____________________Birthdate: ________________________ Relationship to Patient ________________
Employer: ______________________________ Occupation: ___________________ No. Years Employed: __________________
Spouse’s Name: _________________________________________________________Relationship to Patient: _________________
Employer: ______________________________ Occupation: ___________________ No. Years Employed : __________________
Social Security# _____________________Birthdate: ________________________ Work Phone: ___________________________
Insurance Information
Do you have orthodontic coverage? Yes No
Benefit amount: _________________ If no, skip this section.
Insured’s name: ________________________________________________________ Insured’s Soc. Sec. #: _____________________
Insured’s Employer: _____________________________________ Group No. _________________ Local No. _________________
Insurance Company Name & Address: ___________________________________________________________________________
Insurance Company Phone Number: _____________________________________________________________________________
Secondary Insurance?
Yes No
Benefit amount: _________________ If no, skip this section.
Insured’s name: ________________________________________________________ Insured’s Soc. Sec. #: _____________________
Insured’s Employer: _____________________________________ Group No. _________________ Local No. _________________
Insurance Company Name & Address: ___________________________________________________________________________
Insurance Company Phone Number: _____________________________________________________________________________
Emergency Information
Name of nearest relative not living with you: ___________________________________________________________________
Complete Address: ________________________________________________________________________________________________
Home Phone: ___________________________ Cell: ____________________________ Work Phone: __________________________
Authorization and Release
Please Sign and Initial the following:
________ In accordance with HIPPA regulations, I hereby give my permission for the office of Dr. R. Baker
Rawlins to use patient records and information for diagnosis, treatment planning, promotion,
education and insurance purposes.
________ I authorize the dentist to release any information including the diagnosis, and records for treatment
rendered to me or my child, if necessary for insurance purposes. I also authorize direct payment of
insurance benefits to the dentist for services rendered when indicated.
________ I understand that where appropriate, credit bureau reports may be obtained.
Signature (Parent’s signature if minor) _________________________________________________ Date __________________
Updates: (date & initial) ___________________
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CONFIDENTIAL (for record and pretreatment evaluation)
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