Patient / General Information
Patient's First Name:
Patient's Middle Initial:
Patient's Last Name:
Date of Birth:
Age:
Nickname:
Sex:
Male
Female
Address:
City:
State:
Zip:
Patient's Phone:
E-mail Address:
Patient's School and Grade
Brothers/Sisters (Names & Birthdates)
Brothers:
Date of Birth:
Sisters
Date of Birth
If yes, please give details.
Does he/she frequently participate in contact sports?
Play a musical instrument?
What are main extracurricular activites or interests?
Patient's Father
Last Name:
First Name:
Middle Name:
Marital Status:
Single
Married
Divorced
Separated
Widowed
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Social Security #:
E-mail Address:
Birthdate:
Patient's Mother
Last Name:
First Name:
Middle Name:
Marital Status:
Single
Married
Divorced
Separated
Widowed
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Social Security #:
E-mail Address:
Birthdate:
Responsible Party Information (If other than above)
Last Name:
First Name:
Middle Name:
Marital Status:
Single
Married
Divorced
Separated
Widowed
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Work Phone:
Birthdate:
Relationship to patient:
Spouse's Last Name:
Spouse's First Name:
Spouse's Middle Name:
Relationship to patient:
Occupation:
Employer:
# of Years Employed:
Cell Phone:
Work Phone:
Birthdate:
We offer budgeted payment plans; therefore, our office reviews credit bureau information.
Patient Dental History
Dentist Last Name:
Dentist First Name:
Dentist Phone Number:
When was the last dental check up?
Approximate date of last dental x-ray taken:
What is patient's orthodontic problem as you see it?
Has the patient been examined by an orthodontist before? If yes, when?
If yes, please give details.
Any blow or injury to the face or teeth?
Any thumb sucking?
Tooth clenching or grinding (at night)?
Other habits?
Any clicking or pain when he/she opens or closes his/her mouth?
Referral Information
Whom may we thank for referring you to this office?
Area or Address (if available)
Names of close friends or relatives that are patients of this practice:
Patient Medical History
Patient's Physician:
Phone Number:
How is the patient's general health?
Is the patient now under a physician's care? If yes, for what reason?
Is the patient taking any medications at present?
Have medical x-rays been taken in the past year?
Does the patient have:
Any difficulty in breathing through nose?
Any difficulty in swallowing or chewing?
Diabetes?
Asthma?
Rheumatic fever?
Convulsions?
Any contagioius diseases?
Is the patient allergic to anything? (food, drugs, etc.)
Are the patient's tonsils and adenoids present?
Does the patient need to be
premedicated
for any reason?
Insurance Information
Do you have dental insurance?
Yes
No
Who is the primary insurance carrier?
Father
Mother
Other:
Insurance Company:
Phone:
Address:
City:
State:
Zip:
Group Number:
Policy Number:
Local Number: