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Electronic Health History

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1Patient Biographical Information

2Financial Party Information

3Dental History

4Medical History

5Patients Under 18

Patient Biographical Information

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First Name *

Middle Initial

Last Name *

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Nickname

Address *

ZipCode *

Birthday date *

City *

Main Phone *

Gender *

State *

2nd/Cell Phone: *

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Email *

Social Security # *

Please list the names of any friends or family currently in the practice:

List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?

Financial Party Information

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First Name *

Birthdate

Middle Initial:

Relationship to Patient:

Last Name *

Email *

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

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* Main Phone: *

Employer:

Occupation

Length of Employment

Social Security #

Work Phone:

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Do you have insurance that covers orthodontics?

No
Yes

If so, please name the Insurance Company

Dental History

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Dentist Name *

Check-up Frequency

Last Dental Visit

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Has the patient had an orthodontic consult or treatment?

Yes
No

If so, when?

What is the patients main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past.

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Speech problems/therapy? *

No
Yes

Injury to face, jaw, teeth or mouth? *

No
Yes

Pain, tenderness or noise in either jaw? *

No
Yes

Oral habits (thumb/finger sucking, lip/nail biting)? *

No
Yes

Frequent sore throats? *

No
Yes

Floss teeth daily? *

No
Yes

Mouth breathing? *

No
Yes

Requires premedication? *

No
Yes

Apprehensive about dental care? *

No
Yes

Grind or clench teeth? *

No
Yes

Discomfort from teeth or gums? *

No
Yes

Frequent headaches? *

No
Yes

Neck/shoulder pain? *

No
Yes

Brush teeth daily? *

No
Yes

Fluoride treatments? *

No
Yes

Snores during sleep? *

No
Yes

Any missing or extra permanent teeth? *

No
Yes

Frequently Chew Gum? *

No
Yes

If any of the above dental questions were answered 'Yes', please explain:

Medical History

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Physician Name

Date of last Physical

Patient Health

Address

Address Line 1

City

State

Zip Code

List any medications currently being taken by the patient *

Please select YES if the patient has had any of the conditions listed below either now or in the past.

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Rheumatic Fever *

Yes
No

Liver Disease *

Yes
No

Heart Disease *

Yes
No

Hemophilia *

Yes
No

Anemia *

Yes
No

Tonsils/Adenoids Removed *

Yes
No

Received Radiation Treatment *

Yes
No

Hormone Therapy *

Yes
No

Bone Disorders/Bone Loss *

Yes
No

Handicaps/Disabilities *

Yes
No

Treated for Emotional Problems *

Yes
No

Tuberculosis/Lung Disease *

Yes
No

Kidney Disease *

Yes
No

Congenital Heart Defect *

Yes
No

Hypertension/High Blood Pressure *

Yes
No

HIV/AIDS *

Yes
No

Cancer *

Yes
No

Growth Problems *

Yes
No

Latex/Metal Allergy *

Yes
No

Diabetes *

Yes
No

Asthma *

Yes
No

Ever Been Hospitalized *

Yes
No

Pneumonia *

Yes
No

Heart Attack/Stroke *

Yes
No

Heart Murmur *

Yes
No

Prolonged Bleeding/Transfusion *

Yes
No

Hepatitis *

Yes
No

Family History of Cancer *

Yes
No

Endocrine Problems *

Yes
No

Nervous Disorders *

Yes
No

Seizures/Epilepsy *

Yes
No

Arthritis *

Yes
No

Take Bisphosphonates (Fosamax, Boniva) *

Yes
No

If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions:

Please list the name and birthdate of any siblings:

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Height

Grade

Weight

Father/Guardian 1 Name

School

Mother/Guardian 2 Name

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Has patient begun puberty

No
Yes

If patient is a boy, has their voice changed or have facial hair

No
Yes

Patient's interest in treatment:

Has patient begun puberty

No
Yes

Has the patient grown in the past year or has their shoe size changed recently:

No
Yes

Has either biological parent ever had orthodontic treatment:

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OFFICE LOCATIONS

(305) 672-2260
939 Arthur Godfrey Road Miami Beach, FL 33140

(305) 673-2260
1238 NE 163rd Street North Miami Beach, FL 33162

(305) 673-2260
4441 Stirling Road Hollywood,FL 33314

HOURS

Monday – Friday
9am – 6pm
Evening Appointments
Available Upon Request

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