Patient Biographical Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Social Security #:
Address:
City:
State:
Zip:
Primary Phone:
Secondary Phone:
Email:
School:
Grade:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?
List the names of any friends or family currently in the practice:

Parent/Guardian Information

Mother's (or Legal Guardian 1's) First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Social Security Number:
Employer:
Father's (or Legal Guardian 2's) First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Social Security Number:
Employer:

Dental Insurance Information

Policy Holder's Name:
Insurance Company Name:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Subscriber ID:
Group Number:
Do you have secondary dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Insurance Company Name:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Subscriber ID:
Group Number:

Authorization

This office reserves the right to verify credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. And I assign directly to the doctor all insurance.

Signature:
Date:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
What is the patient's main orthodontic concern?
Patient's interest in 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?
Injury to face, jaw, teeth, or mouth?
Clench or grind teeth?
Discomfort from teeth or gums?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Sleeps with mouth open?
Snores during sleep?
Missing or extra permanent teeth?
Apprehensive about dental care?
Oral habits (past or current)?
Pain, tenderness, or noise in either jaw? If so, please describe the specific locations of jaw symptoms, headaches and or neck/shoulder pain:
Frequent headaches?
Neck/shoulder pain?
Frequently chews gum?
Orthodontic procedures require patients to fully recline in a dental chair. Are you able to fully recline in a dental chair?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
Height:
Weight:
Has patient begun puberty (If patient is under age 18)?
Has the patient grown in the past year or has their shoe size changed recently (If patient is under age 18)?
List any medications currently being taken by the patient:
List any 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.
Anemia?
HIV/AIDS?
Hepatitis?
Tonsils/Adeniods Removed?
Cancer?
Family History of Cancer?
Received Radiation Treatment?
Growth Problems?
Endocrine Problems?
Hormone Therapy?
Requires antibiotic premedication?
Rheumatic fever?
Medicated with Bisphosphonates?
Tuberculosis/lung disease?
Latex/metal allergy?
Pneumonia?
Nervous disorders?
Liver disease?
Bone disorders/bone loss?
Kidney disease?
Diabetes?
Heart attack/stroke?
Seizures, epilepsy, or neurological disease?
Heart disease?
Handicaps or disabilities?
Heart defect (congenital)?
Asthma?
Heart murmur?
Arthritis or joint problems?
Hemophilia?
Treated for emotional problems?
High blood pressure or hypertension?
Ever been hospitalized?
Prolonged bleeding or transfusion?
If any of the above medical questions were answered 'Yes' , please explain:

Patients Under 18

Airway History
When sleeping does your child...
Have you ever seen your child stop breathing during the night?
Does your child...
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?
This child often does not seem to listen when spoken to directly.
This child has difficulty organizing tasks and activities.
This child is often easily distracted by extraneous stimuli.
This child often fidgets with hands or feet or squirms in seat.
This child is often 'on the go' or often acts as if 'driven by a motor'.
This child often interrupts or intrudes on others (e.g. butts into conversations or games)
Have your child’s tonsils or adenoids been removed? If so, when?

To the best of my knowledge all the above information is correct and it is my responsibility to inform the office of any changes in medical history. I also authorize the dental staff to perform the necessary orthodontic services. If Airway History is filled out, I consent to the collection of my child’s breathing data along with photos and full orthodontic records for use in scientific research and analysis? If so, please sign below. Thank you.

Parent/Patient Signature:
Date: