Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Cell Phone (main):
Cell Phone (secondary):
Email:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
How did you hear about our office?
Responsible Party Information (If Patient Under 18)
First Name:
Last Name:
Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
City:
State:
Zip:
Insurance Information
Do you have dental insurance?
No
Yes
Insurance Company:
Subscriber:
Date of Birth:
Employer:
Social Security Number:
Subscriber ID#:
Do you have secondary dental insurance?
No
Yes
If yes, Secondary Insurance Company:
Subscriber:
Date of Birth:
Employer:
Social Security Number:
Subscriber ID#:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had a previous orthodontic consult or treatment?
No
Yes
What is the patient's main orthodontic concern?
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?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Floss teeth daily?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Fluoride treatments?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Mouth breathing?
No
Yes
Discomfort from teeth or gums?
No
Yes
Snores during sleep?
No
Yes
Bleeding of gums?
No
Yes
Missing or extra permanent teeth?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Frequently chew gum?
No
Yes
Neck or shoulder pain?
No
Yes
Frequent sore throats?
No
Yes
Baby or permanent teeth removed or extracted?
No
Yes
If any of the above were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
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.
ADD/ADHD?
No
Yes
Anemia?
No
Yes
Asthma?
No
Yes
Autism?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Family history of cancer?
No
Yes
Diabetes?
No
Yes
Endocrine problems?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
High blood pressure or hypertension?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease?
No
Yes
Nervous disorders?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Radiation treatment?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Tuberculosis or lung disease?
No
Yes
If any of the above were answered 'Yes' , please explain:
Is there any other condition or problem that you think we should know about?