New Patient Form

Patient's Appointment Date *

MM

DD

YYYY

Patient Name *

Please include preferred first name in (brackets) if applicable, ie. Jonathan (Jon) Smith.

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Home Phone

If applicable

(###)

###

####

Their address

If different from above

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate of Policy Holder

MM

DD

YYYY

Birthdate of Policy Holder

MM

DD

YYYY

1. Is patient in good health? *

Yes

No

2. History of major illness? *

Yes

No

3. Physical or other difficulties? *

Yes

No

4. Under care of physician? *

Yes

No

5. Frequent colds or sore throats? *

Yes

No

6. Tonsil and adenoid problems? *

Yes

No

7. Any allergic reactions? *

Yes

No

8. Taking any medications? *

Yes

No

9. Heart problems? *

Yes

No

10. Hepatitis? *

Yes

No

11. Acquired Immune Deficiency Syndrome? *

Yes

No

12. Other? *

Yes

No

13. History of thumb/finger sucking? *

Yes

No

14. Is patient a mouthbreather? *

Yes

No

15. Is there a speech problem? *

Yes

No

16. Noise related to jaw joint? *

Yes

No

17. Jaw difficult to open or close? *

Yes

No

18. Pain in jaw joints? *

Yes

No

19. Pain in jaw muscles? *

Yes

No

20. Frequent headaches? *

Yes

No

21. Clenching or grinding habits? *

Yes

No

22. Prior injuries to face or teeth? *

Yes

No

23. Missing or extra teeth? *

Yes

No

24. Mouth musical instrument played? *

Yes

No

Patient's Appointment Date *

MM

DD

YYYY

Patient Name *

Please include preferred first name in (brackets) if applicable, ie. Jonathan (Jon) Smith.

First Name

Last Name

Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian *

First Name

Last Name

Cell Phone *

(###)

###

####

Home Phone

If applicable

(###)

###

####

First Name

Last Name

Cell Phone

If applicable

(###)

###

####

Birthdate of Policy Holder

MM

DD

YYYY

Birthdate of Policy Holder

MM

DD

YYYY

1. Is patient in good health? *

Yes

No

2. History of major illness? *

Yes

No

3. Physical or other difficulties? *

Yes

No

4. Under care of Physician? *

Yes

No

5. Frequent colds or sore throats? *

Yes

No

6. Tonsil and Adenoid problems? *

Yes

No

7. Any allergic reactions? *

Yes

No

8. Are you taking any medications? *

Yes

No

9. Heart problems? *

Yes

No

10. Hepatitis? *

Yes

No

11. Acquired Immune Deficiency Syndrome? *

Yes

No

12. Other? *

Yes

No

13. History of thumb/finger sucking? *

Yes

No

14. Is patient a mouthbreather? *

Yes

No

15. Is there a speech problem? *

Yes

No

16. Are there noises related to the jaw joint? *

Yes

No

17. Is the jaw difficult to open or close? *

Yes

No

18. Pain in jaw joints? *

Yes

No

19. Pain in jaw muscles? *

Yes

No

20. Frequent headaches? *

Yes

No

21. Clenching or grinding habits? *

Yes

No

22. Injuries to face or teeth? *

Yes

No

23. Missing or extra teeth? *

Yes

No

24. Mouth musical instrument played? *

Yes

No