Confidential Patient Information
*First Name: Middle Initial: *Last Name:	*Birthdate:     *Gender: Male Female Nickname:
*Address: *City: *State: *Zip: *Home Phone: Cell Phone: Email:     If patient is under 18 years of age, complete information below. *Father's First Name: *Father's Last Name: *Cell Phone: *Email: Address:     *Mother's First Name: *Mother's Last Name: *Cell Phone: *Email: Address:    If patient is a minor, who does the patient live with?    Select Father Mother Parents 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? Select Dentist Friend Relative Internet Insurance Other     If other:

Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name: *Last Name: Marital Status: Select Single Married Widowed Divorced Separated Relationship to Patient: Select Father Grandparent Guardian Mother Self Spouse Stepfather Stepmother Other     *Home Phone: Cell: Email:	*Address: *City: *State: *Zip:     Employer: Occupation: Work Phone #:
Spouse or Other Parent's First Name Last Name: Marital Status: Select Single Married Widowed Divorced Separated Relationship to Patient: Select Father Grandparent Guardian Mother Self Spouse Stepfather Stepmother Other Home Phone: Cell: Email:	Address: City: State: Zip: Employer: Occupation: Work Phone #:

Dental Insurance Information     Please check if there is no dental insurance. Primary Dental Insurance *Policy Holder's Name/Subscriber's Name: *Subscriber ID # or SS #: *Subscriber's Birthdate: Relationship to Patient: Select Father Grandparent Guardian Mother Self Spouse Stepfather Stepmother Other *Insurance Company: Group No.: Insurance Co. Phone No.: *Policy Holder's Employer: If you have dual dental coverage, please name the Insurance Company below: Secondary Dental Insurance
*Policy Holder's Name/Subscriber's Name: *Subscriber ID # or SS #: *Subscriber's Birthdate: Relationship to Patient: Select Father Grandparent Guardian Mother Self Spouse Stepfather Stepmother Other *Insurance Company: Group No.: Insurance Co. Phone No.: *Policy Holder's Employer:
Emergency Information     *Name of nearest relative not living with you: Complete Address: *Phone: Relationship to Patient: Select Father Grandparent Guardian Mother Self Spouse Stepfather Stepmother Other
Dental History
*Dentist Name: Address: City: State Zip: Phone: Check-up Frequency:    Once per year Twice per year More than twice per year Never Emergencies only Last Dental Visit: Is all dental work complete? NoYes	*Has the patient had an orthodontic consult or treatment? NoYes   If so, when? With whom?
What is the patient's main orthodontic concern?
Does the Patient need to premedicate prior to dental visit?   NoYes
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot leave blank.
NoYes Speech problems/therapy? NoYes Oral habits (thumb/finger sucking, lip/nail biting)? NoYes Abnormal swallowing (tongue thrust)? NoYes Snores during sleep? NoYes Injury to face, jaw, teeth or mouth? NoYes Discomfort from teeth or gums? NoYes Teeth sensitive to hot or cold? NoYes Chipped or injured permanent teeth? NoYes Problems with food trapped between teeth?	NoYes Teeth that irritate tongue, cheek, lip, etc? NoYes Frequent sore throats? NoYes Frequent canker sores or cold sores? NoYes Floss teeth daily? NoYes Previous periodontal (gum) treatment? NoYes Have wisdom teeth been removed? NoYes Any missing or extra permanent teeth? NoYes Previous root canal therapy? NoYes Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:
TMJ (Temporomandibular Joint) History
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot leave blank.

NoYes	Clench teeth?	NoYes	Neck and shoulder pain?
NoYes	Grind teeth?	NoYes	Soreness in your face or around your ears?
NoYes	Jaw joint popping or clicking?	NoYes	Ringing in the ears?
NoYes	Jaw joint soreness?	NoYes	Frequent headaches? (4x a week or more)
NoYes	Locking of jaw?	NoYes	Frequent gum chewing?
NoYes	Difficulty in chewing or opening your mouth?	NoYes	Previous TMJ treatment?
NoYes	Injuries/Trauma to face or jaw?

If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name: Phone:	Date of Last Physical: Patient Health: Select Good Fair Poor
Has there been any change in the patient's general health within the last year?    NoYes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?    NoYes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?    NoYes
List any medications currently being taken by the patient (include non-prescription) and for what conditions?
*Allergies or drug reaction to:
NoYes Latex NoYes Naproxen (Aleve) NoYes Nickel NoYes Ibuprofen (Motrin/Advil) NoYes Antibiotics   What type?  NoYes Tylenol   NoYes Food           What type?   NoYes Other:   List any drug allergies or sensitivities (not listed above) 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 leave blank.
NoYes Heart Murmur NoYes Damaged or artificial heart valves NoYes Congenital Heart Defect NoYes Heart Disease NoYes Rheumatic Fever NoYes Angina NoYes Liver Disease / Jaundice / Hepatitis NoYes Kidney Disease NoYes Heart Attack/Stroke NoYes Hemophilia NoYes Hypertension/High Blood Pressure NoYes Prolonged Bleeding/Transfusion NoYes Anemia NoYes HIV/AIDS NoYes Tonsils/Adenoids Removed NoYes Handicaps/Disabilities NoYes Large Tonsils NoYes Sinus trouble NoYes Substance abuse problem (past or present) NoYes Prosthetic joints NoYes Chronic fatigue	NoYes Diabetes NoYes Growth Problems NoYes Tuberculosis or Lung Disease NoYes Pneumonia NoYes Cancer NoYes Family History of Cancer NoYes Radiation Treatment NoYes Arteriosclerosis NoYes Thyroid / Endocrine Problems NoYes Stomach ulcer or hyperacidity NoYes Hormone Therapy NoYes Nervous Disorders NoYes Bone Disorders/Bone Loss NoYes Seizures / Epilepsy / Neurological Disease NoYes Emotional Problems NoYes Asthma NoYes Respiratory problems / Emphysema NoYes Persistent swollen neck glands NoYes Sexually transmitted disease NoYes Persistant cough NoYes Bisphosphonates Use   --Past or Present NoYes FEMALES: Are you pregnant
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

If patient is under the age of 18, please answer the following questions: Height: Weight: Father's Height Mother's Height: School: Grade:   I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my      knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other      member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there      is any change later to this history record or medical or dental status, I will inform the practice.