Confidential Patient Information

Patient First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Identify As:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID #/Social Security #:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID #/Social Security #:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

What is the patient's main orthodontic concern?
Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
How does the patient feel about orthodontic treatment?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems or therapy?
Clench or grind teeth?
Oral habits (thumb or finger sucking, lip or nail biting)?
Injury to face, jaw, teeth, or mouth?
Discomfort from teeth or gums?
Pain, tenderness, or noise in either jaw?
Frequent headaches?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste or mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Missing or extra permanent teeth?
Apprehensive about dental care?
Frequently chew gum?
Thumb or finger habit as a child?
Jaw fractures, cysts, or mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Local anesthetics?
Latex / Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Angina?
Anemia or blood disorder?
Arteriosclerosis?
Arthritis or joint problems?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Bone fractures or trauma to face or jaw?
Cancer?
Cancer in family history?
Chronic fatigue?
Diabetes?
Emotional problems treatment?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Heart valves are damaged or artificial?
Hemophilia?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Low blood pressure?
Nervous disorders?
Persistent cough?
Persistent swollen neck glands?
Pneumonia?
Prolonged bleeding or transfusion?
Prosthetic joints?
Radiation treatment?
Respiratory problems or emphysema
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Herpes / Cold Sores?
Sinus trouble?
Stomach ulcer or hyperacidity?
Substance abuse problem (past or present)?
Thyroid or endocrine problems?
Tonsils enlarged?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:
Is there anything you would like to discuss with the doctor in private?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
School:
Grade:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either biological parent ever had orthodontic treatment?