You may complete the Patient History form below and submit the data online. You can also download and print the following PDF file and bring the completed form to your first visit. Please fill out all items to your best knowledge.

    PATIENT INFORMATION

  • Do you have any dental work in progress at this time?YesNo
  • Patient's Sex:MaleFemale

  • Is Patient a Student?YesNo

  • What interests or hobbies does the patient enjoy?
  • If patient is a child, give parent or legal guardian name:
  • What would the patient/parent like most to have orthodontic treatment accomplish?

    SIBLINGS

    RESPONSIBLE PARTY

  • Marital Status:SingleMarriedSeparatedDivoredWidowed

  • After reviewing the treatment plan, I authorize the release of any information related to this claim. I authorize payment of dental benefits directly to Montano Elevated Orthodontics.

    EMERGENCY INFORMATION

    HEALTH HISTORY

  • 1. Is the patient's health considered to be good?YesNo
  • 2. Is patient under medical treatment?YesNo
  • 3. Is patient currently taking any medication?YesNo
  • 4. Has patient ever taken medication for osteoporosis, such as Bisphosphonate. Boniva etc?YesNo
  • 5. Is patient allergic to any drug or antibiotics such as medication, asprin, Penicillin, etcs?YesNo
  • 6. Has patient ever had an unfavorable reaction following dental treatment?YesNo
  • 7. Has patient had a cough for more than three weeks that is not explained by Non-infectious condition or exhibiting flu-like symptoms or diagnosed with H1N1?YesNo
  • 8. Female patients: Are you pregnant?YesNoN/A
  • 9. Does patient use tobacco?YesNo
  • 10. Has patient ever taken appetitie suppressants such as Fen-Phen (Fenfluramine and Phentermine), Dexfenfluramine Fenfluramine?YesNo
  • 11. Has patient been under the care of a medical doctor since taking any of the appetite suppressants named above?YesNo
  • 12. Does patient have or had any of the following conditions?
    AIDSArthritisAsthmaBleeding ProblemsCancerDiabetesEpilepsyHeart MurmurHeart ProblemsHepatitisHerpesHigh Blood PressureJaundiceKidney ProblemsLow Blood PressureRheumatic FeverStrokeTuberculosisVenereal Disease

    AUTHORIZATION

  • Patient Medical Dental History (ADULT) Health Insurance Portability and Accountability Act of 1996 (HIPAA).