Elliot Jolley, DMD
www.jolleyorthodontics.com
Vernal
582 North 1700 WestVernal, UT, 84078
(435) 781-1234
Roosevelt
481 West 200 NorthRoosevelt, UT 84066
(435) 722-1233
www.jolleyorthodontics.com
Patient's First and Last Name
Prefered Name
Date of Birth
Gender
Social Security Number
Address
City
State
Zip Code
Prefered Phone Number
Alternate Phone Number
Email Address
Are You A Student?
If so, what school to you attend?
Who is you Dentist?
Date of Last Dental Vist
Who is you Physician?
Date of Last Physician Vist
Were your reffered to us?
If so, by whom?
First and Last Name
Relation to Patient
Date of Birth
Marital Status
Spouse (If Applicable)
Employer (If Applicable)
Social Security Number
Address
City
State
Zip Code
Prefered Phone Number
Alternate Phone Number
Email Address
As a courtesy to our patients, we will be happy to file insurance claims on your behalf. We can provide pre-authorizations if needed and are working to help you maximize your insurance benefits. To have claims processed in a timely manner we do need a copy of your dental insurance card, and the following infomation filled out completely.
Do you have dental insurance?
Insurance Company
Policy ID Number
Group Number
Effective Date
Is it an Employer Plan?
Employer Name
Employer Address
City
State
Zip Code
Employer Phone Number
Check the box if you have, or if you ever had, any of the following
☐ Birth Defects of Hereditary Problems
☐ Bone Fractures, any Major Accidents
☐ Rheumatoid or Arthritic Conditions
☐ Endocrine or Thyroid Problems
☐ Kidney Problems
☐ Diabetes
☐ Cancer, Tumor, Radiation treatment, or Chemotherapy
☐ Stomach Ulcer or Hyperacitity
☐ Polio, Mononucleosis, Tuberculosis, or Pnemonia
☐ Problems of the Immune System
☐ AIDS or HIV Positive
☐ Hepatitis, Jaundice, or Liver Problems
☐ Fainting Spells, Seizures, Epilepsey, or Neurological Problems
☐ Mental Health Disturbance or Depression
☐ Vision, Hearing, Tasting, or Speech Difficulties
☐ Rapid Weight Loss, Poor Appetite
☐ Eating Disorders (Anorexia, Bullima)
☐ Excessive Bleeding or Bruising Tendency, Anemia, or Bleeding Disorder
☐ High or Low Blood Pressure
☐ Tired Easilly
☐ Chest Pain, Shortness of Breath, or Swelling Ankles
☐ Cardiovascular Problems (Hear Trouble, Heart Attack, Angina, Coronary Insufficiency, Arterosclerosis, Stroke, Inborn Heart Defects, Heart Murmer, or Rheumatic Heart Disease)
☐ Skin Disorder
☐ Freaquent Headaches, Colds, or Sore Throats
☐ Eye, Ear, Nose, or Throat Condition
☐ Hayfever, Asthma, Sinus Trouble, or Hives
☐ Tonsil or Adenoid Conditions
☐ Osteoporosis
☐ Substance Abuse Problems
☐ Chewed or Smoked Tobacco
☐ Are You Prenant?
☐ Are You Currently Taking Birth Control?
☐ Metals (Jewlery, Clothing Snaps)
☐ Latex (Gloves, Balloons)
☐ Vinal
☐ Acrylic
☐ Other (Please Specify)
Please List any Medication, Dietary Supplements, Herbal Medications, or Non-Perscription Medicine You are Currently Taking
Check the box if you have, or if you ever had, any of the following
☐ Permanent or "Extra" (Supernumerary) Teeth Removed
☐ Teeth Sensitive to Hot or Cold; Teeth Throb or Ache
☐ "Dead Teeth" or Root Canals Treated
☐ Peridontal "Gum Problems"
☐ "Gum Boils", Frequent Canker Sores or Cold Sores
☐ Abnormal Swallowing Habbit (Tongue Thrusting)
☐ Mouth Breating Habbit, Snoring, or Difficulty Breathing
☐ Any Pain, Clicking, or Locking of the Jaw or Ringing in the Ears
☐ Local Anesthetics (Novocain or Lidocaine)
☐ Aware of any Loose, Broken, or Missing Restorations (Filling)
☐ Any Relatives with Similar Tooth or Jaw Relationships
☐ Had Peridontal (Gum) Treatment
☐ Concerned about Spaced, Protruding, or Crooked Teeth
☐ Supernumerary (Extra) or Congenitally Missing Teeth
☐ Jaw Fractures, Cysts, or Mouth Infections
☐ Bleeding Gums, Bad Taste, or Mouth Odor
☐ Food Impactions Between Teeth
☐ History of Speech Problems
☐ Tooth grinding or Jaw Clenching
☐ Difficulaty Chewing or Opening Jaw
☐ Been treated for TMD or TMJ
☐ Any Teeth Irritating Cheek, Lip, Tongue, or Palate
☐ Wisdom Teeth Problems
☐ Had any Serious Touble Associated with any Previous Dental Treatment
☐ Aware or Concerned About Under or Over Developed Jaw
☐ Prior Orthodontic Examination or Treatment
☐ Thumb, Finger, or Sucking Habbit Until Age
Have you ever been under another dentist's or dental specialist's care? If so, who? Also, what was their field of specialty if applicable.
How Often do you Brush?
How Often do you Floss?
What are your primary Concerns? Why are you here?
Anything else we should know?
I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history, record or medical/dental status, I will so inform this practice.
Signature
Date