PATIENT INFORMATION
Patients Name
Last
First
Middle
Address
Street

City
State
Zip
Home Phone Birth date

Age

S.S.N. E-mail address

School Grade
Siblings / Children     (Names and ages please)
If patient is a minor, give parent's or guardian's name.
How did you hear of our office? 

RESPONSIBLE PARTY INFORMATION
Name Marital Status

Last
First
Middle
Residence
Street

City
State
Zip
Mailing Address
Street

City
State
Zip
How long at this address Home Phone Work Phone
Previous Address
(if less than 3 years )
Street

City
State
Zip
Social Security # Birth date Relationship to Patient
Employer Occupation Number Years Employed
Spouse's Name  Relationship to Patient

Last
First
Middle
Employer Occupation Number Years Employed
Social Security # Birth Date Work Phone
INSURANCE INFORMATION
Insured's Name Insured's Social Security #
Insured's Employer
Insurance Company Group Number Local Number
 
Insurance Company Address
Insurance Phone Number
Do you have dual coverage? Yes           No 
Insured's Name Insured's Social security #
Insured's Employer
Insurance Company Group Number Local Number
Insurance Company Address
Insurance Company Phone Number
Insured's Employer
Medical History
Family Physician
Phone Number
Date of Last Visit
 
YES NO     YES NO  
Are you taking any medication ? Have you had any major operations ?
Are you allergic to any medications ? Have you ever been involved in a serious accident ?
Do you have a history of a major illness ?      

Have you ever had any of the following diseases or medical problems
YES NO     YES NO  
Abnormal Bleeding / Hemophilia Hepatitis / Liver Problems
Anemia Herpes
Arthritis High Blood Pressure
Asthma or Hayfever HIV + / AIDS
Bone Disorders Kidney Problems
Congenital Heart Defect Nervous Disorders
Diabetes Pneumonia
Dizziness Prolonged Bleeding
Epilepsy Radiation / Chemotherapy
Gastrointestinal Disorders Rheumatic Fever
Heart Problems Tuberculosis
Heart Murmur Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
PATIENT DENTAL HISTORY
General Dentist
Date of Last Visit
Dentist Phone Number
What Concerns you most about your teeth ?
  YES NO
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth or teeth?
Is any part of your mouth sensitive to temperature or pressure ?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit ?
Are you a mouth breather?
Have you ever seen an orthodontist ?
Has anyone in the family received orthodontic treatment ?
How did they feel about the result ?
What is your attitude toward orthodontic treatment ?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping ?
Are you aware of clenching your teeth during the day ?
Have you ever been told that you grind your teeth ?
Do you have "tension" headaches ?
Have you ever experienced chronic ringing in your ears ?
Are you aware some appointments will be during school / work hours ?




8769 North Main Street
Dayton, Ohio 45415
Phone: (937) 890-9600

72 Remick Boulevard
Springboro, OH 45066
Phone: (937) 886-2700
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