Health History Form

Patient Information

Name*

First Last

Sex*

M
F

Birthdate*

Age*

(For children) Patient lives with:

Mom
Dad
Both

Marital Status of parents:

Single
Married
Divorced
Remarried
Other

Who may we thank for referring you to our office?

Responsible Party Information

Name*

First Middle Last

Relationship to Patient*

Address*

Street Address City State ZIP Code

Home Phone*

Cell Phone

Email*

Employer

Occupation

Work Phone

Responsible Party, Other

Name

First Middle Last

Address

Street Address City State ZIP Code

Home Phone

Cell Phone

Employer

Occupation

Relationship to Patient

Dental Insurance Information

Insurance Carrier's Name

Group #

Subscriber's Name

First Middle Last

Subscriber's ID#

Subscriber's Date of Birth

Subscriber's Employer

Patient's Medical History

Please answer yes or no to the following:

Fainting/Dizziness*

Yes
No

Bone Disorder*

Yes
No

Neurological Disorder*

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

Do you snore*

Yes
No

Do you have sleep apnea*

Yes
No

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

List any drug allergies or drug sensitivities.

List any drug/medications now being taken.

Are you allergic or sensitive to latex?*

Yes
No

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

Do the jaws ever "lock" or get stuck?*

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

Is there apprehension about orthodontic treatment?*

Yes
No

Last dental visit?

Were x-rays taken?

Yes
No

What are your primary concerns?

I authorize John S Woo, DDS MS to release any information including diagnosis and the records of any treatment or examination rendered to my child or 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 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 my dependents. I understand that payment is due at the time of service unless other arrangements have been made.

Signature:*

Please type your name here. Typing your name here will serve as your E-signature.

Date:*

Please fill out our secure Health History Form

Patient Information

Responsible Party Information

Responsible Party, Other

Dental Insurance Information

Patient's Medical History