Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Sex:
Preferred Pronouns:
Mailing Address:
City:
State:
Zip:
Main Phone:
2nd Phone:
Email:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of any family that has had treatment in our office:
Whom may we thank for referring you to our practice?

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Mailing Address:
City:
State:
Zip:
Email:
Main Phone:
2nd Phone:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Employer:
Occupation:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone:
Policy Holder's Social Security #:
Policy Holder's Birthdate:
Do you have additional dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Social Security #:
Policy Holder's Birthdate:

Dental History

Dentist Name:
Check-up 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?
Brush teeth daily?
Floss teeth daily?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Any missing or extra permanent teeth?
Discomfort from teeth or gums?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Bad taste/mouth odor?
Frequent canker sores or cold sores?
Problems with food trapped between teeth?
Previous periodontal (gum) treatment?
Apprehensive about dental care?
Is all dental work complete?
If any of the above dental questions were answered 'Yes', please explain:
Snores during sleep?
Tired during day?
Stopped breathing during sleep?
Abnormal swallowing (tongue thrust)?
Mouth breathing?
Speech problems/therapy?
If any of the above dental questions were answered 'Yes', please explain:
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?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Clench or grind teeth?
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/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
Penicillin or Other Antibiotics
Sulfa Drugs
Aspirin, Ibuprofen, Tylenol
Local Anesthetics
Codeine or Other Narcotics
Metal Allergy
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 be blank.
Heart Murmur
Damaged or Artificial Heart Valves
Congenital Heart Defect
Heart Disease / Angina
Heart Attack / Stroke
Rheumatic Fever
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Anemia / Blood Disorder / Prolonged Bleeding
Hypertension / High Blood Pressure
HIV/AIDS
Tonsils/Adenoids Removed
Large Tonsils
Sinus Trouble
Lung / Breathing Disorder
Tuberculosis
Pneumonia
Asthma
Respiratory Problems / Emphysema
Bone Disorders / Bone Loss
Arthritis / Joint Problems
Prosthetic Joints
Diabetes
Thyroid / Endocrine Problems
Growth Problems
Hormone Therapy
Cancer
Received Radiation Treatment
Take Bisphosphonates (Fosamax, Boniva)
Chronic Fatigue
Family History of Cancer
Arteriosclerosis
Stomach Ulcer or Hyperacidity
Sexually Transmitted Disease
Treated for Mental Health Disorders
Seizures / Epilepsy / Neurological Disease
Tobacco Use
Alcohol Use
Drug Use
Substance Abuse Problem
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:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or does he 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:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by answering the following questions.

What is your main orthodontic concern?
Teeth - Is there anything you would like to change about the appearance of your teeth?
Face - Is there anything you would like to change about the appearance of your smile?
Symptoms - Do you have any concerns with your bite (difficulty biting into foods, pain opening or closing)?