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Patient Health History

Patient Details

Patient First Name

Patient Last Name

Middle Name

Birthday

Nickname: (I prefer to be called)

Gender

Address

Email

Home Phone

Cell Phone

Work Phone

School

Who can we thank for this referral?

Other family seen by this office

First Name

Last Name

Relationship to Patient

Date of Birth MM/DD/YYYY

Address

Home Phone

Cell Phone

Work Phone and extension

First and Last Name

Relationship to patient

Phone Number

First Name

Cell Phone

Last Name

Work Phone

Birthday

First Name

Insured SSN/ID (XXX/XX/XXXX)

Last Name

Relationship to Patient

Employer Name

DOB Insured

Dental Insurance Company

Your Signature

Physician

Is the patient currently taking any medications?

Physician Phone Number

If you answered yes to the previous, please list?

Please list any medications you are allergic to:

Please check any conditons that apply:

Abnormal/Prolonged bleeding/Hemophilia

Anemia

Arthritis

Asthma/Allergies

Autoimmune Disorder

Bone Disorders

Diabetes

Dizziness

Epilepsy

GI Disorders

Heart Problems

Hepatitis/Liver Problems

Herpes

High Blood Pressure

HIV/AIDS

Kidney Problems

Pneumonia

Nervous/Anxiety Disorder

Radiation/Chemotherapy

Skin Disorder

Thyroid Disorder

Tuberculosis

Tumor or Cancer

Please feel free to expand on any of the above, or let us know of any other issues or operations we should be aware of:

General Dentist

Date of Last Visit:

What concerns the patient most about his/her teeth?

Please list any injuries to the face, mouth or teeth:

Is the patient currently in any dental pain? If yes, please explain:

Has the patient ever experienced a reaction to dentistry? If yes, please explain:

Please check any and all that apply:

Chronic ringing in the ears

Clenching/grinding during the day

Clicking or popping of jaw

Mouth breathing

Sensitive to temperature or pressure

Sore jaw or teeth when waking up

Tension headaches

Thumb or tongue habit

Is the patient currently taking or has taken intravenous bisphosphonates for bone cancers such as Zometa (zoledronic acid) or Aredia (pamidronate)? If yes, please describe dosage and duration:

Is the patient currently taking or has been given oral or intravenous bisphosphonates for osteoporosis, osteopenia, or other uses such as Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Reclast (zoledronic acid), Skelid (tiludronate), Didronel (etidronate), or Bonefos (clodronate)? If yes, please describe below:

Your Signature

Thanks for submitting!

www.ulrichorthodontics.com

team@ulrichorthodontics.com

530.885.8331

Fax 530.885.6036

Monday-Thursday 7:45 a.m.-5 p.m.

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