Patient Forms | Chelsea Orthodontics

Patient Biographical Information

Name*

First Middle Last

Birthday*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone*

Secondary Phone

Gender*

SSN

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

Check if the patient is also the person who will be financially responsible for treatment.

Name*

First Middle Last

Birthay*

Relationship to Patient*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone*

Second Phone

Do you have insurance that covers orthodontics?*

Yes
No

If so, please name the Insurance Company below:

Employer

Occupation

Length of Emplyment

Work Phone

Dental History

Dentist Name

Check-up Frequency

Last Dental Visit

Has the patient had an orthodontic consult or treatment?

If yes 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.

Speech problems/therapy?

Yes
No

Grind or clench teeth?

Yes
No

Injury to face, jaw, teeth or mouth?

Yes
No

Discomfort from teeth or gums?

Yes
No

Pain, tenderness or noise in either jaw?

Yes
No

Frequent headaches?

Yes
No

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

Yes
No

Neck/shoulder pain?

Yes
No

Frequent sore throats?

Yes
No

Brush teeth daily?

Yes
No

Floss teeth daily?

Yes
No

Fluoride treatments?

Yes
No

Snores during sleep?

Yes
No

Mouth breathing?

Yes
No

Requires premedication?

Yes
No

Any missing or extra permanent teeth?

Yes
No

Apprehensive about dental care?

Yes
No

Frequently Chew Gum?

Yes
No

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

Medical History

Physician Name:

Date of last Physical:

Patient Health:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

List any medications currently being taken by the patient:

List any drug allergies or sensitivities that the patient may have:

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

Rheumatic Fever

Yes
No

Pneumonia

Yes
No

Tuberculosis/Lung Disease

Yes
No

Liver Disease

Yes
No

Kidney Disease

Yes
No

Heart Attack/Stroke

Yes
No

Heart Disease

Yes
No

Congenital Heart Defect

Yes
No

Heart Murmur

Yes
No

Hemophilia

Yes
No

Hypertension/High Blood Pressure

Yes
No

Prolonged Bleeding/Transfusion

Yes
No

Anemia

Yes
No

HIV/AIDS

Yes
No

Hepatitis

Yes
No

Tonsils/Adenoids Removed

Yes
No

Cancer

Yes
No

Family History of Cancer

Yes
No

Received Radiation Treatment

Yes
No

Growth Problems

Yes
No

Endocrine Problems

Yes
No

Hormone Therapy

Yes
No

Latex/Metal Allergy

Yes
No

Nervous Disorders

Yes
No

Bone Disorders/Bone Loss

Yes
No

Diabetes

Yes
No

Seizures/Epilepsy

Yes
No

Handicaps/Disabilities

Yes
No

Asthma

Yes
No

Arthritis

Yes
No

Treated for Emotional Problems

Yes
No

Ever Been Hospitalized

Yes
No

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

New Patient Form

Patient Biographical Information

Financial Party Information

Dental History

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

Medical History

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