Burkhardt Patient Registration

Patient Information & Health History Form

Patient First Name

MI

Patient Last Name

Date of Birth

Age

Gender

Male Female

Patient living with:

Other

Is patient adopted?

Yes No

Marital Status of biological parents/ patient:

Married Divorced Separated Other

Other

School / School District

How did you hear about us?

Other family members seen by us:

Siblings/ Ages:

HOUSEHOLD #1

Self Mother/Father Stepmother/Stepfather Guardian

First Name

MI

Last Name

Address

City

State

Zipcode

Home Phone

Work Phone

Ext.

Cell Phone

Email

Employer Name

Secondary Contact

Relationship to Patient

Home Phone

Cell Phone

HOUSEHOLD #2

Mother/Father Stepmother/Stepfather Guardian

First Name

MI

Last Name

Address

City

State

Zipcode

Home Phone

Work Phone

Ext.

Cell Phone

Email

Employer Name

Secondary Contact

Relationship to Patient

Home Phone

Cell Phone

EMERGENCY CONTACT INFORMATION (Name of nearest relative not living with the patient)

Emergency Contact

Relationship to patient

Phone #

Address

City

State

Zipcode

PATIENT PROFILE

Does patient have learning disabilities or need help with instructions?

Yes No

Please explain:

Realizing that successful orthodontic treatment greatly depends upon the patient’s complete cooperation in following instructions, keeping appointments and maintaining oral hygiene, are there any restrictions, challenges or problems that might be encountered during treatment?

Yes No

Please explain:

Physician

Date of last physical

Are there any impending medical conditions / procedures?

Yes No

Please list:

Is patient taking any prescriptions, herbal and/or homeopathic medications? 

Yes No

Please list:

ALLERGIES

Latex

Yes No

Metal

Yes No

Seasonal / grasses

Yes No

Food

Yes No

Drug

Yes No

Other

Yes No

If yes, please specify below.

PATIENT MEDICAL HISTORY

Current speech issues?

Yes No

If yes, has patient had speech therapy?

Yes No

Describe:

Does patient require pre-medication or antibiotics before dental appointments?

Yes No

Describe:

Has patient received medical treatment from an allergist or ear, nose and throat specialist?

Yes No

If yes, when?

By whom?

Nasal surgery?

Tonsils removed?

Adenoids removed?

Do you have, or have had, any of the following?

ADD/ADHD

Yes No

Anemia

Yes No

Anxiety

Yes No

Arthritis

Yes No

Artificial joints / valves

Yes No

Asthma/ difficulty breathing/ respiratory issues

Yes No

Autism

Yes No

Birth defects/ congenital defects

Yes No

Breathe through mouth

Yes No

Cancer

Yes No

Chewing or swallowing difficulties

Yes No

Cold sores/ oral ulcers/ herpes

Yes No

Diabetes

Yes No

Endocrine problems

Yes No

Emotional problems

Yes No

Epilepsy/ seizures

Yes No

Fainting

Yes No

Frequent colds

Yes No

Headache/ migraine

Yes No

Heart condition/ murmur

Yes No

Head or face injury

Yes No

Hemophilia/ abnormal bleeding

Yes No

Hepatitis

Yes No

HIV/ Hep C positive

Yes No

Kidney / Liver disease

Yes No

Osteoporosis

Yes No

Previous surgeries

Yes No

Sleep Apnea

Yes No

Snoring while sleeping

Yes No

Thyroid problems

Yes No

Tuberculosis

Yes No

Other

Yes No

PTSD

Yes No

List Triggers

Recent concussion

Yes No

When?

If yes to any of the above, please explain below:

FEMALES ONLY

Is the patient pregnant?

Yes No

If yes, date due:

CHILDREN & ADOLESCENTS ONLY

Has puberty been reached? (start of menstruation or voice change)

Yes No

If yes, when:

DENTAL INFORMATION

Family dentist:

Date of last dental exam:

How many times per day does patient brush?

Does patient floss daily?

Yes No

Has patient ever been treated for TMJ (jaw joint) problems?

Yes No

Pain or clicking in jaw/joint?

Yes No

Does jaw joint “lock”, “get stuck” or feel “unusual”?

Yes No

Pain with chewing, yawning or opening wide?

Yes No

Pain in or about the ears or cheeks?

Yes No

Has the patient ever had any unusual dental experiences?

Yes No

If yes, please explain:

Additional information:

THE FOLLOWING HABITS ARE OF INTEREST. LIST INFORMATION AS IT PERTAINS TO THE PATIENT

Thumb/ finger/ lip sucking?

Yes No

Until what age?

Grinding or clenching of teeth?

Yes No

High intake of sweets / soda?

Yes No

Tongue thrusting or other functional problems?

Yes No

Smoking history?

Never Currently Past

Are there any needed restorations?

Yes No

Date/estimated date of completion:

Has patient had a previous orthodontic consultation or treatment?

Yes No

With whom?

When?

What is the primary concern for orthodontic treatment?

Are there any additional concerns or questions that the doctor should be aware of or you wish the doctor to answer?

FORM COMPLETION

I have read and understand the above questions. I will not hold my orthodontist or any member of his/ her staff responsible for any errors or omissions that I have made in the completion of this form. I understand that it is my responsibility to contact this office with any changes in my medical/ dental status.

First Name

Last Name

Signature

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Date

Provider Signature

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Date

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