New Patient Information
Office Location
Which office are you visiting?OremNorth OgdenLaytonRivertonWest ValleyWest JordanRoySugarhouse
Patient Name
Date of Birth
Age
Sex
MF
I prefer to be called
Marital Status
Spouse's Name
Patient's Address
City
Zip Code
SSN #
Email Address
Home Phone
Cell Phone
Cell Carrier
Occupation
Employer
Employer Phone
Emergency Contact
Phone
Relationship to You
How did you hear about our office?
How did you hear about our practice?Internet - Web SearchInternet - Google AdFacebookRadioHometown ValuesLocation/Drive ByMedicaidInsuranceYellow PagesReturning PatientFriend/Current PatientMy Dentist
Please state what you feel is wrong with your teeth
Name of Dentist
Last Seen
Reason
Name of Dental Office
Dental Insurance Information
Primary Policy Holder's Name
SSN#
Insurance Company Name
ID#
Secondary Policy Holder's Name
If you would like to tell us more about why you are considering braces, please use the box below
If the patient is under 18 years old, please fill out this section if you are the parent or legal guardian of the patient.
Patient Parent's Name
Relation to Patient
Dental History
Now or in the past, have you had:
Any teeth removed for any reason?
YesNo
Supernumerary (extra) or congenitally missing teeth?
Chipped or otherwise injured primary (baby) or permanent teeth?
Jaw Fractures, cysts or mouth infections?
Periodontal problems,bleeding gums, bad taste or mouth odor?
Thumb, finger or sucking habit?
YesNoUntil what age?
Abnormal swallowing habit (tongue thrusting)?
History of speech problems?
Mouth breathing habit, snoring or difficulty in breathing?
Tooth grinding, jaw clenching clicking or locking
Any pain in jaw or ringing in the ears?
Treatment for “TMD” or “TMJ” problems?
Aware of loose, broken or missing restorations (fillings)?
Have adenoids or tonsils been removed?
Any problems with wisdom teeth?
Is patient sensitive or self-conscious about teeth?
Ever had a prior orthodontic exam or treatment?
How often do you brush?
How often do you floss?
Do you smoke or chew tobacco?
Medical History
Operations or surgeries?
Describe
Congenital Heart Defect?
Abnormal Bleeding?
Diabetes?
Cancer, tumor, radiation treatment or chemo?
Heart Murmur?
Handicaps/Impairment?
Convulsion/Epilepsy?
Asthma?
Hemophilia?
HIV/AIDS?
Vision, hearing, tasting or speech difficulties?
Mental health disturbance or behavioral problems?
Are you Pregnant?
Do you anticipate becoming pregnant?
Are there any other medical conditions that we should be aware of?
Check allergies or reactions to any of the following:
AspirinPenicillin or other antibioticsLatex(gloves, balloons)Vinyl, Acrylic or AnimalsIbuprofen(Motrin, Advil)TylenolSulfa DrugsMetals (jewelry, nickel)Foods (specify)
Please list any medication, nutrient supplements, Herbal medications or nonprescription medicine Being taken by the patient.
I have read and understand the above questions. I will not hold my treating doctor or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will be sure to inform this practice. Furthermore, I consent to an orthodontic examination and if necessary, orthodontic records which include photos, impressions and x-rays.
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