**PLEASE COMPLETE ALL REQUIRED (*) FIELDS PRIOR TO SUBMISSION**
Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd Phone:
Email:
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
No
Yes
Primary Dental Insurance
Primary Member's First Name:
Primary Member's Last Name:
Primary Member's DOB:
Insurance Company:
Insurance Company Address:
Subscriber ID#/SSN:
Employer:
Occupation:
Work Phone:
Secondary Dental Insurance
Secondary Member's First Name:
Secondary Member's Last Name:
Secondary Member's DOB:
Insurance Company:
Insurance Company Address:
Subscriber ID#/SSN:
Employer:
Occupation:
Work 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?
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.
Antibiotic premedication required or needed?
No
Yes
Apprehensive about dental care?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Frequently chew gum?
No
Yes
Frequent headaches?
No
Yes
Frequent sore throats?
No
Yes
Have you ever had extractions?
No
Yes
Have you ever had periodontal treatment?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Neck or shoulder pain?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions 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.
ADHD?
No
Yes
Anemia or blood disorder?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Autism?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
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
Hepatitis?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Ever been hospitalized?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease or jaundice?
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
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
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:
Please list the name and birthdate of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Address:
Cell Phone:
Email:
Marital Status:
Mother/Guardian 2 Name:
Address:
Cell Phone:
Email:
Marital Status:
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
**PLEASE COMPLETE ALL REQUIRED (*) FIELDS PRIOR TO SUBMISSION**