Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Date of Birth:
Gender:
Male
Female
Other
Street Address:
City:
State:
Zip:
Main Phone:
Secondary Phone:
Email:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date of Birth:
Social Security Number:
Address:
City:
State:
Zip:
How long at this address?
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
First Name:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date of Birth:
Social Security Number:
Address:
City:
State:
Zip:
How long at this address?
Email:
Main Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
Dental Insurance Information
Policy Holder's Name:
Date of Birth:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Date of Birth:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Emergency Contact Information
Nearest relative not living with you.
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
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 an orthodontic consult or treatment?
No
Yes
If so, when?
Does the Patient need to premedicate prior to dental visit?
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.
Apprehensive about dental care?
No
Yes
Bleeding gums?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Jaw fractures, cysts, or mouth infections?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
Is all dental work completed at this time?
No
Yes
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.
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Codeine or other narcotics?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Metal?
No
Yes
Penicillin or other antibiotics?
No
Yes
Sulfa drugs?
No
Yes
Other?
No
Yes
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.
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bed wetting?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Bone fractures or trauma to face or jaw?
No
Yes
Chronic fatigue?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart valves are damaged or artificial?
No
Yes
Hemophilia?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Nervous disorders?
No
Yes
Persistent swollen neck glands?
No
Yes
Prosthetic joints?
No
Yes
Respiratory problems
No
Yes
Substance abuse problem (past or present)?
No
Yes
Thyroid or endocrine problems?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
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.
I understand that where appropriate, credit bureau reports may be obtained.