Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Male
Female
General Dentist:
If Applicable
Employer:
Cell Phone:
Best Email:
Parent Information
Father's Information
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Job Title:
Employer:
Phone #:
Email:
Mother's Information
Check if mother's address is the same as father's.
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Job Title:
Employer:
Phone #:
Email:
Patient Resides With:
Both Parents
Mother
Father
Other
Best Contact Information
Name:
Relationship:
Best Number:
Person Financially Responsible For Account
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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
No
Yes
Frequent Stuffed Nose
No
Yes
Thumb or Finger Sucking Habit
No
Yes
Previous Orthodontic Treatment
No
Yes
Sleep Apnea
No
Yes
Bleeding Disorder
No
Yes
Heart Murmur
No
Yes
Behavioral Problems
No
Yes
Epilepsy
No
Yes
Heart Disease
No
Yes
Pregnant
No
Yes
Frequent headaches?
No
Yes
Hepatitis
No
Yes
Rheumatic Fever
No
Yes
Drug Sensitivities
No
Yes
Tongue Tie
No
Yes
Mouth Breather
No
Yes
Osteoporosis/Osteopenia
No
Yes
Does the patient have any special problems not listed above?
Did patient breastfeed?
No
Yes
For how long?
Any difficulty nursing?
No
Yes
Does the patient have any jaw clicking when opening or closing?
No
Yes
Has the patient been under the care of a physician in the past two years other than routine checks? If so, for what?
No
Yes
Is the patient currently taking any medications? If so, please list.
For children and teens, has patient reached puberty?
No
Yes
Females: has menstruation begun?
No
Yes
At what age?
Month/Year:
Airway and Sleep Evaluation
Please Indicate if the patient has any of the following:
Difficulty breathing when asleep:
Never
Occasionally
Frequently
Stops breathing during sleep:
Never
Occasionally
Frequently
Snores:
Never
Occasionally
Frequently
Restless sleep:
Never
Occasionally
Frequently
Excessive movement during sleep:
Never
Occasionally
Frequently
Night terrors:
Never
Occasionally
Frequently
Sleep walking or talking:
Never
Occasionally
Frequently
Daytime sleepiness:
Never
Occasionally
Frequently
Daytime Hyperactivity (ADD/ADHD):
Never
Occasionally
Frequently
Teeth grinding:
Never
Occasionally
Frequently
Bed wetting:
Never
Occasionally
Frequently
Acid reflux:
Never
Occasionally
Frequently
Chews with mouth open:
Never
Occasionally
Frequently
Daytime breathing through mouth:
Never
Occasionally
Frequently
Lips apart during the day:
Never
Occasionally
Frequently
Dark circles under eyes:
Never
Occasionally
Frequently
*
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I agree to allow Annapolis Orthodontics to use images taken of my child before, during and after treatment for education/training purposes.
E-Signature:
Relationship:
Date: