Medical History Adult "*" indicates required fields Step 1 of 5 20% Please select the location where your appointment will be held:ManhattanRiverdaleFirst Name*Last NamePatient Birthdate* MM slash DD slash YYYY Gender*MaleFemaleOtherMarital Status*MarriedSeperatedDivorcedWidowedSingleSocial Security #*Email* Cell Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Occupation*Employer*Person Responsible for Account* Self Spouse Other (provide info below) If "Other," please fill out the following information. Alternatively, skip to the next section - Dental Insurance.Responsible Party - NameResponsible Party - EmailResponsible Party - Cell Phone NumberResponsible Party - SSNResponsible Party - Address Dental InsurancePrimary Insurance Company NameSSN Or Member IDOrthodontic Coverage Yes No Unsure Insured's NameInsured's DOB MM slash DD slash YYYY Photo of Insurance Card - Front & Back Please! Drop files here or Select files Max. file size: 50 MB. Secondary Insurance CompanySecondary Insurance - SSN Or Member IDSecondary Insurance - Orthodontic Coverage Yes No Unsure Secondary Insurance - Insured's NameSecondary Insurance - Insured's DOB MM slash DD slash YYYY Secondary Insurance - Photo of Insurance Card (front & back please!) Drop files here or Select files Max. file size: 50 MB. Dental HistoryPatient's Dentist*Date of Last Visit* MM slash DD slash YYYY Please tell us if the answer is Yes to any of the below questions:* Have there been any injuries to the face / mouth or teeth? Has the patient been informed of any missing or extra permanent teeth? Is the patient aware of any lumps / sores or irritated areas in the mouth? Does the patient have any speech problems? Is the patient frightened or anxious about orthodontic treatment? Is the patient concerned about the appearance of their teeth? Has the patient had or presently have any of the following habits: Thumb or Finger Sucking / Lip Biting / Snoring / Grinding of Teeth at Night / Mouth Breathing Has there ever been any orthodontic treatment for any other member of the family in our practice? Has an orthodontist been consulted previously? The answer is No for all of the above questions. If the patient has been previously had an orthodontic consult, please tell us who provided the consult:If any children in your family are being treated by our practice, please list their full names below:Has the patient ever been treated for any of the following? (If yes, please tell us by whom in the other box)* Bad Bite Periodontal Disease TMJ None of the above Other OtherWhat aspect of treatment is the patient most concerned with?* Quality Cost Discomfort Time Other Other Medical HistoryIs the patient's general health good at this time?* Yes No If no, please explain:What is the name of the family physician?*If the patient is currently under the care of a physician, please tell us why:If the patient is taking any medication, please list all of them below:If the patient is allergic to any medications, please list them all below:Has the patient ever had tonsils or adenoids removed? If so, tell us at what age in the other box below* Yes No Other If the patient has ever had a serious illness or been hospitalized, please elaborate below:If the patient has any special problems, please explain below:If the patient has ever been advised by their physician to take an antibiotic prior to any dental treatment, please list antibiotic and method below:Patient's Approximate Height*Patient's Approximate Weight*Please indicate if the answer is YES for any of the below questions: Are you pregnant or considering pregnancy during the next 2 years? Are you nursing? Are you currently taking medication for birth control? Has the patient ever had any of the following - now or in the past:* Endocarditis Respiratory Lung Disease Glaucoma Heart Condition High Blood Pressure Fainting Spells Heart Pacemaker Low Blood Pressure Kidney Trouble Heart Angina Hepititis None of the above If Hepatitis, please list type:Has the patient ever had any of the following - now or in the past:* Liver Disease Tuberculousis Psychiatric Treatment Venereal Disease Drug Addiction Herpes (oral coldsores) Headaches Ear Aches Blood Disorders / Bleeding Problems Congenital Heart Disease Heart Attack (coronary) Mitral Valve Prolapse Artificial Heart Valve Heart Surgery None of the above If Heart Surgery occurred, please list date:Has the patient ever had any of the following - now or in the past:* Inflammatory Rheumatism Jaw Clicking Heart Murmur Arthritis Allergies Rheumatic Fever Ulcers Allergies to Metal Prosthetic (artificial) Joint Stroke Jaw Pain X-ray / Radiation (Cancer) Therapy Anemia Tonsillitis AIDS or HIV Positive Asthma Emotional Problems Diabetes Epilepsy None of the above Informed ConsentI, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION OR INFORMATION NOT DISCLOSED.Signature*Date* MM slash DD slash YYYY
