Patient's Personal Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Phone number (mobile preferred):
Email:
If patient is a minor, give parent's or guardian's name:
How did you hear about our practice?
Friends/Family (please state name)
Dentist Referral (please state name)
Google Search
Social Media
Insurance Company
If more than one referrer or not listed above, please state name(s):
Responsible Party Information
Check if you are the patient and will be financially responsible for the treatment fees.
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:
Phone number (mobile preferred):
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Phone number (mobile preferred):
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder’s Date of Birth (XX/XX/XXXX):
Insurance Company:
Subscriber ID #:
Policy Holder’s Social Security Number:
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:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder’s Date of Birth (XX/XX/XXXX):
Insurance Company:
Subscriber ID #:
Policy Holder’s Social Security Number:
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
Patient Dental History
Does the patient have a dentist that they see on a regular basis?
No
Yes
If Yes, please enter their name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Does the Patient need to premedicate prior to dental visit?
No
Yes
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
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
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
Jaw Fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
No
Yes
Additional dental work needed?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
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
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 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:
Reason for Seeking Orthodontic Evaluation
What is the patient’s main orthodontic concern? i.e. What would the patient like to fix about his/her smile?
Has the patient had previous orthodontic treatment?
No
Yes
If so, when and where?
Has the patient had or is scheduled for another orthodontic consultation?
No
Yes
If so, with whom and when?
What treatment option are you most interested in hearing about during your consultation?
Treat all upper and lower teeth to straighten and correct bite
Treat a specific issue with your smile
Early treatment to intervene and correct something at a young age
Interested in something else? Please explain.
What treatment modality would you like to use to improve your smile? Check all that apply.
Invisalign Clear Aligners
Traditional Braces
If orthodontic treatment is recommended, finances for treatment will be discussed during your appointment. We offer various payment options to our patients and can customize the structure of your financial contract to best suit your needs. Please let us know what is most important to you:
Low down payment
Low monthly payments
Pay in Full Discounts
Are you moving out of the area within the next 6 months?
No
Yes
Patient Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
Are you taking any medications (including non-prescription)?
No
Yes
If Yes, please list below.
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
Metal Allergy
No
Yes
Any additional drug allergies or sensitivities not listed above?
No
Yes
If Yes, please list below.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Angina
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Large Tonsils
No
Yes
Sinus trouble
No
Yes
Bed wetting
No
Yes
Substance abuse problem (past or present)
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Prosthetic joints
No
Yes
Chronic fatigue
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Disease
No
Yes
Pneumonia
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Arteriosclerosis
No
Yes
Thyroid / Endocrine Problems
No
Yes
Stomach ulcer or hyperacidity
No
Yes
Hormone Therapy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Treated for Emotional Problems
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
Persistent swollen neck glands
No
Yes
Sexually transmitted disease
No
Yes
Low blood pressure
No
Yes
Persistent cough
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
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:
Height:
Weight:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has his voice changed or has he gotten facial hair?
No
Yes
Has the patient grown in the past year or has his/her shoe size changed recently?
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.
PLEASE REVIEW AND MAKE SURE ALL QUESTIONS WITH A RED ASTERISK ‘
*
’ HAVE BEEN ANSWERED BEFORE CLICKING "SUBMIT". FORM WILL NOT SUCCESSFULLY SUBMIT IF ALL QUESTIONS WITH A RED ASTERISK ARE NOT FILLED OUT.