Patient Information

First Name:
MI:
Last Name:
Nickname:
General Dentist:
Birthdate:
Age:
Gender:
Address:
City:
State:
Zip:
Cell Phone:
Phone:
Email:
Employer:
Job Title:

Person Financially Responsible For Account

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:

Orthodontic Insurance Information

Primary Insurance Company:
Name of Subscriber:
ID or Social Security #:
Group #:
Birthdate of Subscriber:
Employer:
Insurance Phone Number:
Secondary Insurance Company:
Name of Subscriber:
ID or Social Security #:
Group #:
Birthdate of Subscriber:
Employer:
Insurance Phone Number:

Health History

Please indicate if the patient has or had the following:
Allergies/Asthma
Frequent Stuffed Nose
Thumb or Finger Sucking Habit
Previous Orthodontic Treatment
Sleep Apnea
Bleeding Disorder
Heart Murmur
Behavioral Problems
Epilepsy
Heart Disease
Pregnant
Frequent headaches?
Hepatitis
Rheumatic Fever
Drug Sensitivities
Tongue Tie
Mouth Breather
Osteoporosis/Osteopenia
Does the patient have any special problems not listed above?
Does the patient have any jaw clicking when opening or closing?
Has the patient been under the care of a physician in the past two years other than routine checks? If so, for what?
Is the patient currently taking any medications? If so, please list.

Airway and Sleep Evaluation

Difficulty breathing when asleep:
Stops breathing during sleep:
Snores:
Restless sleep:
Excessive movement during sleep:
Night terrors:
Sleep walking or talking:
Daytime sleepiness:
Daytime Hyperactivity (ADD/ADHD):
Teeth grinding:
Bed wetting:
Acid reflux:
Chews with mouth open:
Daytime breathing through mouth:
Lips apart during the day:
Dark circles under eyes:
E-Signature:
Relationship:
Date: