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Health History
Home/Health History


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First Name*
Last Name*
Gender*
Address*
MM slash DD slash YYYY

How did you hear about us? Please check below.

Check All That Apply

Responsible Party Information
If patient is under 18, responsible party must complete this section.

Full Name*

Dental Insurance Information

Policy Holder's Name*
MM slash DD slash YYYY
Do you have dual insurance coverage?

If you have dual coverage, please provide information on your secondary insurance below.

Policy Holder's Name*
MM slash DD slash YYYY

Dental History

MM slash DD slash YYYY
Have you had previous orthodontic treatment?
Have there been any injuries to your face, mouth or teeth?
Are you presently in any dental pain?
Do your gums bleed when you brush your teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your teeth or jaws ever feel uncomfortable?
Do your jaws make any clicking or popping noises?
Do you clench your teeth during the day?
Have you ever been told that you grind your teeth?
Have you ever experienced chronic ringing in your ears?
Do you have 'tension' headaches?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Do you have blisters or sores on your lips and/or in your mouth?
Do you have a burning sensation on your tongue?
Do you smoke cigarettes, cigars, a pipe, etc.?
Do you have sensitivity to cold, hot, and/or sweets?

Medical History

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

MM slash DD slash YYYY
Are you taking any medication?
Are you allergic to any medication?
Do you have a history or any major illness?
Are you or have you ever taken Bisphosphonates for osteoporosis?
Have you ever been involved in a serious accident?

Please check any of the following that you have had or currently have:

I have the following

Women

Are you pregnant?
MM slash DD slash YYYY
Are You Nursing?
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