Patient Medical Information Form - Upstate Orthodontics

ADVERTISEMENT

Chart # __________________
Date _________________
Patient’s Name ___________________________________________ Nickname ____________________ Age _____
First
Last
Social Security Number _______________________________ Date of Birth ____________________ Sex ________
Address ________________________________________________________________________ Zip ___________
Home Phone ______________________ Cell Phone _____________________Work Phone ____________________
Employer _______________________________ Employer Address _______________________________________
Occupation _______________________________________ Email Address _________________________________
School _________________________ Dentist ________________________ Physician _______________________
Responsible Party ___________________________________ Patient Resides with ___________________________
Father
Mother
If patient is under 18 please fill out the following:
Name
_____________________________________
_______________________________________
SS#/DOB
_______________________/______________
__________________________/_____________
Employer
_____________________________________
_______________________________________
Employer’s Address
_
____________________________________
_______________________________________
Occupation
_____________________________________
_______________________________________
Parents’ Marital Status:
Married ______
Widow (er) ______
Separated ______
Divorced ______
Single ______
Other children treated in our practice: ________________________________________________________________
Reason for Orthodontic Examination ________________________________________________________
How did you decide to come to this office? ___________________________________________________
Orthodontic Insurance Information
Orthodontic Coverage Yes / No / Unsure
Father/Self (circle one)
Mother/Spouse (circle one)
Name of Ins. Co. ______________________________
Name of Ins. Co. ___________________________
Patient Medical Information
Are you allergic to: Penicillin?
Yes / No
Have you ever worn orthodontic appliances before?
Yes / No
Local Anesthetic?
Yes / No
Are you under the care of a physician?
Yes / No
Other medications or drugs?
Yes / No
If yes, Why__________________________________________
If so what? _____________________________
Do you have or have you ever had:
Are you taking any medications for osteoporosis? (bisphosphates)
injury to the teeth or jaws?
Yes / No
Yes / No
birth defect or handicap?
Yes / No
List any medications you are currently taking ___________________
asthma or breathing problems?
Yes / No
________________________________________________________
heart disease, murmer or rheumatic fever?
Yes / No
Do you have any other medical conditions that we should be aware of?
immunosuppressant disorders?
Yes / No
_________________________________________________________
seizures or other neurological disorders?
Yes / No
What would you like your orthodontic treatment to accomplish? _____
bleeding problems?
Yes / No
_________________________________________________________
liver disease or hepatitis?
Yes / No
For young ladies: have you begun your menstrual cycles?
Yes / No
epilepsy or other seizures?
Yes / No
Are you Pregnant?
Yes / No

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Medical Information Form Patient Medical Information Form Medical
Patient Medical Information Form Patient Medical Information Form Medical
Senderra Specialty Pharmacy Patient & Medical Information Form Senderra Specialty Pharmacy Patient & Medical Information Form Medical
Senderra Specialty Pharmacy Patient & Medical Information Form Senderra Specialty Pharmacy Patient & Medical Information Form Medical
Patient Medical Information Patient Medical Information Legal
Patient Medical Information Check In Sheet - Aoa Arizona Patient Medical Information Check In Sheet - Aoa Arizona Medical
Patient Authorization For The Release Of Medical Information Form Patient Authorization For The Release Of Medical Information Form Legal
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical
Patient Medical History Form Patient Medical History Form Medical

Related Categories

Parent category: Medical
Download
Go