Patient Information Form

Patient Information

Name*

First Middle Last

Is the patient a child, teen or an adult?*

Child
Teen
Adult

Phone (if adult)

Email (if adult)*

Sex*

M
F

Birthdate*

Age*

Marital Status of Parents

Single
Married
Divorced
Remarried
Other

(For Children) Patient lives with:

Mom
Dad
Both

Who may we thank for referring you to our office?

Patient's Dentist

Responsible Party

Name*

First Middle Last

Address*

Street Address City State ZIP Code

Email*

Home Phone*

Cell Phone

Work Phone

Employer

Occupation

Responsible Party's Spouse

Name

First Middle Last

Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Work Phone

Employer

Occupation

Relationship to Patient

Dental Insurance Information

Do you have Dental Insurance?

Yes
No

Insurance Carrier's Name

Group #

Subscriber's Name

First Middle Last

Subscriber's ID #

Subscriber's Date of Birth

Subscriber's Employer

Medical History

Fainting/Dizziness*

Yes
No

Bone Disorders*

Yes
No

Neurological Disorders*

Yes
No

Blood Pressure*

Yes
No

Asthma*

Yes
No

Diabetes*

Yes
No

Heart Trouble*

Yes
No

Epilepsy*

Yes
No

Liver (Hepatitus)*

Yes
No

Prolonged Bleeding*

Yes
No

Thyroid*

Yes
No

Positive HIV Virus (AIDS)*

Yes
No

Rheumatic Fever*

Yes
No

Kidneys*

Yes
No

Arthritis of any kind*

Yes
No

Is there any other medical problem (or history of) that we should be aware of? Please explain:

Please list any drug allergies or drug sensitivities.

List any drug/medications now being taken.

Are you allergic/sensitive to latex?*

Yes
No

Dental History

Have there been any injuries to the teeth, mouth or jaws?*

Yes
No

Thumb or finger sucking?*

Yes
No

Until what age?

Are any teeth especially sensitive?*

Yes
No

Do the jaw joints make noise (clicking, popping, or grating sounds?)*

Yes
No

Is there pain in front of, behind, or in your ears?*

Yes
No

Is there difficulty when chewing or opening wide?*

Yes
No

Is there tension or spasms in the head or neck?*

Yes
No

Is stress or nervous tension affecting this problem?*

Yes
No

Are there headaches in the morning, noon, or evening?*

Yes
No

Have you had a previous orthodontic examination?

Yes
No

When was your last dental visit?

Were X-rays taken?

What are your primary concerns?

I authorize Dr. John S. Woo and Dr. Marc DeBerardinis to release any information, including diagnosis, records of treatment, or examination rendered to my child or to me during this period of such dental care to third party payors and/or other health practitioners. I give release for the office to use my photographs and the first initial or name of my child or self for office bulletin displays and/or office websites. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

Signature*

Date*

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