331 Wilmington Pike • Suite 5

Glen Mills, PA 19342

610.358.0600

153 Little Conestoga Road

Chester Springs, PA 19425

610.458.1600

New Patient Health History Form

New Patient Health Form
Last Name (*)
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First Name (*)
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Middle Name
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Street Address (*)
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City (*)
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State (*)
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Zip
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Phone No (*)
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Cell No
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Email Address (*)
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Age
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Birth Date
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Gender
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If the patient is a dependent, please complete the following:
Father's Name
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Phone No
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Cell No
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Work No
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Mother's Name
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Phone No
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Cell No
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Work No
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Person to contact in case of emergency
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Phone No
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Relation to patient
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Insurance Information

Primary Insurance
Name of Insured (*)
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Relaton to Patient
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Insured Date of Birth
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Insured Social Sec No
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Insurance Name
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Insurance Phone No
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Insurance Address
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Insurance ID
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Group No
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Employer
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Employer Phone
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Employer Address
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Secondary Insurance, if applicable
Name of Insured
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Relation to Patient
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Insured Date of Birth
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Social Security No
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Insurance Name
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Phone No
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Insurance Address
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Insurance ID
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Insurance Group No
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Employer
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Employer Phone No
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Employer Address
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Dental History
Patient's General Dentist
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Date of last visit
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Dentist Address
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Dentist Phone No
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The following questions are directed to the patient:
1. Have you previously consulted an orthodontist?
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If Yes, When?
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2. Is there a family history of missing teeth?
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If so, who
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3. Do your gums bleed while brushing your teeth?
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4. Is there any part of your mouth sensitive to temperature?
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5. Is any part of your mouth sensitive to pressure
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6. Have you ever sucked your thumb or fingers?
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If so, have you stopped this habit?
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If Yes, when?
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7. Have you had your tonsils/adenoids removed?
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8. Do you clench or grind your teeth during the day?
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9. Are you aware of any clenching or grinding at night?
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10. Do you now, or have you ever had, pain in your jaw joint of the sides of your face (in and about the ears)?
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11. Have you ever had clicking or popping in your jaw joint?
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If yes, Please explain
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12. Have you ever experienced pain when you open your mouth wide?
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If yes, please explain
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13. Have you had any injury to your jaw?
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If yes, please explain
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14. Have you had any injury to your teeth?
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Medical History


The following questions are directed to the patient
Primary Care Physician
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Primary care phone no
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Primary Care Address
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Patient's General Health and known illnesses
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Present Medications
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Please list any surgeries including dates
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1. Is there any possibility that you could be pregnant?
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2. Have you ever had an allergic reaction to medication?
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If yes, please list medications:
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3. Have you ever had an allergic reaction to food?
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If yes, please list foods:
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Have you ever had any of the following?
Bleeding History
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Cancer
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Diabetes
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Hearing Loss
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Epilepsy
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Liver Problems
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High Blood Pressure
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Migraine Headaches
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Stomach Ulcers
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Hepatitis
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Kidney Problems
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AIDS or other immune system disorder
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Damaged heart valves (e.g. mitral valve prolapse, artificial heart valve, heart murmur)
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If yes, do you need to be premedicated?
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Any history of cardiovascular disease (e.g. heart trouble, heart attack, coronary insufficient, coronary occlusion, arteriosclerosis, stroke)
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Security Security
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Submit