Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Social Security #:
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Main Phone:
Social Security Number:
Dental Insurance Information
Do you have insurance that covers orthodontics?
No
Yes
Unsure
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
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:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
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.
Apprehensive about dental care?
No
Yes
Clench or grind teeth?
No
Yes
Frequent headaches?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Requires premedication?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Any Dental concerns Doctor should know?
Medical History
Physician Name:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Any medical conditions doctor should be aware of?
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Diabetes?
No
Yes
Growth problems?
No
Yes
Handicaps/Disabilities?
No
Yes
HIV or AIDS?
No
Yes
Seizures/Epilepsy?
No
Yes
Any behavioral issues doctor should be aware of?
Any growth or developmental issues doctor should be aware of?
Any allergies (Food, latex, etc.)?
No
Yes