Confidential Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
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 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?
Confidential Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Employer:
Occupation:
Work Phone #:
Dental Insurance Information
Orthodontic Coverage?
Yes
No
Policy Holder's Name:
Policy Holder's DOB:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's DOB:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Current Dentist?
Yes
No
Dentist Name:
Last Dental Visit:
Last Dental Cleaning:
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.
Speech problems/therapy?
No
Yes
Clench or Grind Teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw Fractures, cysts, mouth infections?
No
Yes
Problems with food trapped between teeth?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Do you clench your teeth?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Do you experience any facial pain?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Physician Phone Number:
Has the patient had a any hospitalization? If so, what for?
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex / Metal Allergy
No
Yes
List any drug allergies or sensitivities (not listed above) that the patient may have:
Does the patient have any medical conditions?
Yes
No
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Problems
No
Yes
Liver Problems / Jaundice / Hepatitis
No
Yes
Kidney Problems
No
Yes
Hypertension/High Blood Pressure/Low Blood Pressure
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Physical Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Sinus trouble
No
Yes
Bed wetting
No
Yes
Substance abuse problem (past or present)
No
Yes
Prosthetic joints
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Problems
No
Yes
Pneumonia
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Thyroid / Endocrine Problems
No
Yes
Gastrointestinal Disorders
No
Yes
Hormone Therapy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Osteoporosis
No
Yes
Seizures / Epilepsy / Neurological Problems
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
FEMALES: Are you pregnant
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Sensory Disorder
No
Yes
Autism Spectrum Disorder
No
Yes
Attention Deficit Hyperactivity Disorder
No
Yes
Patient Motivation for Orthodontic Treatment
Straighten Front Teeth
Upper
Lower
Both
Straighten Back Teeth
Upper
Lower
Both
Move Upper Teeth
Forward
Backward
Move Lower Teeth
Forward
Backward
Eliminate Spaces Between Teeth
Upper
Lower
Both
Eliminate Crowding of Teeth
Upper
Lower
Both
Make Line of Upper Teeth More Level
Other
Patients Under 18
If patient is under the age of 18, please answer the following questions:
School:
Grade:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
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.