Havener Orthodontics
Email: info@havenerorthodontics.com
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New Patient Forms
New Patient Form – Adult
New Patient Form – Under 18
Contact Us
New Patient Form – Adult
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Patient
Patient Name
First
Middle
Last
Title
Mr.
Mrs.
Ms.
Miss.
Dr.
Other
I prefer to be called:
Title (other)
Birth Date
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1994
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1961
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1952
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1950
1949
1948
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1946
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1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Age
Sex
Male
Female
Social Security Number
Marital Status
Single
Married
Separated
Divorced
Widowed
Email
Home Address
City, State, Zip
Home Phone
Cell Phone
Occupation
Employer
Work Phone
Closest Relative
Spouse or closest relative name
Spouse or relative title
Mr.
Mrs.
Ms.
Miss.
Dr.
Other
Relationship to patient
Other (spouse or relative title)
Spouse or relative's address (if different)
Spouse or relative's cell phone
Spouse or relative's home phone (if different)
Spouse or relative's work phone
Dentist
Patient's Dentist
Address, City, State
Date Last Seen
Reason
Next Appointment Date
General Information
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations:
Have any other family members been treated in this office? Please name them:
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account?
Home Address
City, State, Zip
Home Phone
Cell Phone
Email
Social Security Number
Employer
Dental Insurance
Do you have dental insurance?
Yes
No
Primary policy holder’s full name
Social Security Number
Relationship to patient
Date of Birth
Address
Phone Number
Employer
Insurance company
Group #
ID #
Do you have dual coverage
Yes
No
Secondary policy holder’s full name
Social Security Number
Relationship to patient
Date of Birth
Address (if different)
Phone Number (if different)
Employer
Does this policy have orthodontic benefits?
Yes
No
Don't Know
Physician
Patient's Physician
Physician's Phone
Patient Health Information
Do you take antibiotic pre-medication before any dental procedures?
Yes
No
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Have you ever taken any medications to strengthen your bones? Please describe:
Have you noticed any unusual changes in your face or jaws?
Yes
No
Any other physical problems?
Yes
No
Please explain
How often do you brush?
How often do you floss?
Are you pregnant?
Yes
No
Are you trying to become pregnant?
Yes
No
Medical History
Now or in the past, have you had: (Check all that apply)
Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Do you frequently breathe through his/her mouth?
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?
Have you had allergies or reactions to any of the following? (check all that apply)
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances
Other substances (please explain)
Dental History
Now or in the past, have you had: (check all that apply)
Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Have you been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?
Please review your answers before submitting the form.
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