Gainesville: (352) 331-5132 | Lake City: (386) 754-0092 Request an Appointment

Gainesville and Lake City, FL Orthodontists

About Us
The Progressive Difference
Testimonials
Get Started
Treatment
Treatment Types
Our orthodontists offer core and supplemental treatment options that enhance your final results.

Ages
Our team is committed to offering orthodontic treatment for children, teens, adults, and even seniors.

Care
We’re here to help you with oral hygiene tips, emergency situations, and everything in between.
Blog
Contact
- Request an Appointment

Gainesville: (352) 331-5132 | Lake City: (386) 754-0092

About Us
The Progressive Difference
Testimonials
Get Started
Treatment
Treatment Types
Our orthodontists offer core and supplemental treatment options that enhance your final results.

Ages
Our team is committed to offering orthodontic treatment for children, teens, adults, and even seniors.

Care
We’re here to help you with oral hygiene tips, emergency situations, and everything in between.
Blog
Contact
- Request an Appointment

Gainesville: (352) 331-5132
Lake City: (386) 754-0092

About Us
The Progressive Difference
Testimonials
Get Started
Treatment
Treatment Types
Our orthodontists offer core and supplemental treatment options that enhance your final results.

Ages
Our team is committed to offering orthodontic treatment for children, teens, adults, and even seniors.

Care
We’re here to help you with oral hygiene tips, emergency situations, and everything in between.
Blog
Contact
- Request an Appointment

Uplift, Encourage, Inspire

Health History Form

Health History FormProgressive Orthodontic Associates2023-10-24T13:42:41+00:00

Please Fill Out the Form Below

New Patient Health History

"*" indicates required fields

Patient Biographical Information

First Name*

Middle Initial

Last Name*

Nickname

Birthdate*

MM slash DD slash YYYY

Gender*

Address*

City*

State*

Zip*

Main Phone*

2nd / Cell Phone

Email*

Social Security #

Please list the names of any friends or family currently in the practice:

List any sports, hobbies, or musical instruments played:

Whom may we thank for referring you to our practice?

Financial Party Information

First Name*

Middle Initial

Last Name*

Birthdate*

MM slash DD slash YYYY

Relationship to Patient*

Email*

Address*

City*

State*

Zip*

Main Phone*

2nd / Cell Phone

Social Security #

Employer*

Occupation*

Length of Employment*

Work Phone

Do you have insurance that covers orthodontics?*

Yes

If so, please name the Insurance Company:*

Dental History

Dentist Name*

Checkup Frequency*

Last Dental Visit

MM slash DD slash YYYY

Has the patient had an orthodontic consult or treatment?*

Yes

If so, when?*

MM slash DD slash YYYY

What is the patient's main orthodontic concern?

Speech problems / therapy?*

Yes

Grind or clench teeth?*

Yes

Injury to face, jaw, teeth, or mouth?*

Yes

Discomfort from teeth or gums?*

Yes

Pain, tenderness, or noise in either jaw?*

Yes

Frequent headaches?*

Yes

Oral Habits (thumb / finger sucking, lip / nail biting)?*

Yes

Neck / shoulder pain?*

Yes

Frequent sore throats?*

Yes

Brush teeth daily?*

Yes

Floss teeth daily?*

Yes

Fluoride treatments?*

Yes

Mouth Breathing?*

Yes

Snores during sleep?*

Yes

Requires premedication?*

Yes

Any missing or extra permanent teeth?*

Yes

Apprehensive about dental care?*

Yes

Frequently chew gum?*

Yes

If any of the above dental questions were answered "Yes," please explain:

Medical History

Physician Name*

Date of Last Physical

MM slash DD slash YYYY

Patient Health*

Address*

City*

State*

Zip*

List of any medications currently being taken by the patient:

List of any drug allergies or sensitivities that the patient may have:

Rheumatic Fever*

Yes

Tuberculosis / Lung Disease*

Yes

Pneumonia*

Yes

Liver Disease*

Yes

Kidney Disease*

Yes

Heart Attack / Stroke*

Yes

Heart Disease*

Yes

Congenital Heart Defect*

Yes

Heart Murmur*

Yes

Hemophilia*

Yes

Hypertension / High Blood Pressure*

Yes

Prolonged Bleeding / Transfusion*

Yes

Anemia*

Yes

HIV / AIDS*

Yes

Hepatitis*

Yes

Tonsils / Adenoids Removed*

Yes

Cancer*

Yes

Family History of Cancer*

Yes

Received Radiation Treatment*

Yes

Growth Problems*

Yes

Endocrine Problems*

Yes

Hormone Therapy*

Yes

Latex / Metal Allergy*

Yes

Nervous Disorders*

Yes

Bone Disorders / Bone Loss*

Yes

Diabetes*

Yes

Seizures / Epilepsy*

Yes

Handicaps / Disabilities*

Yes

Asthma*

Yes

Arthritis*

Yes

Treated for Emotional Problems*

Yes

Ever Been Hospitalized*

Yes

If any of the above medical questions were answered "Yes," please explain:

Patients Under 18

Please the name and birth date of any siblings:

Height

Weight

School

Grade

Father / Guardian 1 Name

Mother / Guardian 2 Name

Has patient begun puberty?

Yes

If patient is a girl, has menstruation begun?

Yes

If patient is a boy, has their voice changed or have facial hair?

Yes

Has the patient grown in the past year or has their shoe size changed recently?

Yes

Has either biological parent ever had orthodontic treatment?

Yes

Patient's interest in treatment?

Signature*

Date*

MM slash DD slash YYYY

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

7 Plus Invisalign Provider Gainesville Florida

Invisalign Teen Provider Gainesville And Lake City Florida

Itero Digital Orthodontist Gainesville And Lake City Florida

Gainesville And Lake City Florida Orthodontists

Gainesville

7575 W University Ave, Ste E
Gainesville, FL 32607

(352) 331-5132

Hours:

Mon-Fri: 8am-5pm

Lake City

457 SW Perimeter Glen
Lake City, FL 32025

(386) 754-0092

Hours:

Mon-Thu: 8am-5pm | Fri: 8am-3pm (Phone Only)

Treatment Types

Ages

Care

Treatment Types

Ages

Care

Treatment Types

Ages

Care

Uplift, Encourage, Inspire

Health History Form

Please Fill Out the Form Below

New Patient Health History

Patient Biographical Information

Financial Party Information

Dental History

Medical History

Patients Under 18

Gainesville

Hours:

Lake City

Hours: