TABACCHI ORTHODONTICS
New Patient History Form
Date:
Patient Information
Patient’s Name:
Date of Birth:
Gender:
Social Security No.:
Address:
Home Phone:
Patient’s School:
Patient’s Dentist:
Address:
Patient’s Physician:
Address:
If patient is a minor, give parent’s/guardian’s name and contact information
Mom’s name:
Home Phone:
Address:
Work Phone:
Dad’s name:
Home Phone:
Address:
Work Phone:
Patient living with:
Mother
Father
Other:
Siblings and ages:
Patient’s e-mail address:
Mom/Dad/Guardian’s e-mail address:
Responsible Party Information
Name:
Marital Status:
Residence:
Mailing Address:
How long at this address:
Home Phone:
Work Phone:
Previous Address (if less than 3 years):
Social Security No.:
Birth Date:
Relationship to Patient:
Employer:
Occupation:
No. Years Employed:
Spouse’s Name:
Relationship to Patient:
Employer:
Occupation:
No. Years Employed:
Social Security No.:
Birth Date:
Work Phone:
Insurance Information
Insurance will be filed as a service to you by our office. Please present your insurance card upon arrival of the new patient examination
.
Please confirm your insurance benefits for your own information
.
Insured’s Name:
Insured’s Soc. Sec. No.:
Insurance Company:
Group No.:
Phone No.:
Insurance Co. Address:
Insured’s Employer:
Ins Co Phone:
Do you have dual coverage?
Yes
No
If Yes, complete the following:
Insured’s Name:
Insured’s Soc. Sec. No.:
Insurance Company:
Group No.:
Policy No.:
Insurance Co. Address
Insured’s Employer:
Emergency Information
Person to be contacted in case of emergency (other than parents):
Name:
Relationship to patient:
Address:
Phone:
Patient’s Medical History
Please check any of the following if your answer is “Yes”
Require antibiotics for dental treatment due to heart murmur/heart condition
Is your child in a rapid growth time?
Has menstruation begun? (girls)
Any unusual reaction to dental anesthesia?
Are you pregnant?
Are you allergic to any medications?
If ‘yes’, which ones:
Do you have or have you had any of the following conditions:
Diabetes
Prolonged Bleeding
Epilepsy
Heart Attack/Stroke
Rheumatic Fever
Bone Disorders
Tuberculosis
Hepatitis
AIDS or HIV
Cancer
Anemia
Asthma
Fainting or Dizziness
Nervous Disorder
Endocrine Problems
Liver Problems
Birth Defects
Allergies
Fever Blisters
Latex Allergy
Metal Allergy
Drug/Alcohol Abuse
Brain Injury
Radiation Treatment
Any other medical conditions we should know about:
Are you on any medications? Please list:
Patient’s Dental History
Please check any of the following if your answer is “Yes”, then explain
Any family members who have had orthodontics?
Teeth sensitive to hot/cold?
Injuries to your face,jaw,mouth or teeth?
Bleeding gums, bad taste in mouth?
Root canals, crowns, bridges, bondings, veneers?
Suck your thumb/fingers?
Any Clicking, popping or pain of the jaw joints (TMJ)?
Any missing teeth or extra teeth?
Trouble chewing?
Have you been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?
Have you had previous orthodontic treatment? When?
Do you have sores, swelling, or blisters on your gums, cheeks, or lips? Where?
How long present (if more than 2 weeks)?
Date of most recent dental exam:
How often do you Brush?
Floss?
Other Information Details
What is the main thing you would like to find out by coming to see Dr. Tabacchi, and what would you like to see done to your smile?
Patient’s attitude towards orthodontic treatment:
Very Motivated
Somewhat Motivated
Not Motivated
Who may we thank for referring you to our office?
Is there anyone else in the family who may need an exam?
Any other important information:
Would you be interested in the payment plans available in the office?
I understand the information I have given today is correct to the best of my knowledge. I also understand this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my/my child’s medical status.
I understand this office may verify the credit status of potential patients/parents of patients prior to extending credit for treatment fees, and may obtain a credit bureau report. (This will not reflect on your credit report due to a health care inquiry.)