Personal Information

First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
Zip:
Home Phone:
Birthdate:
Age:
School:
Hobbies & Interests
Gender:

Parent's Information

Father
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Employer Address:
City:
Zip:
Work Phone:

Mother
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
Zip:
Phone:
Cell Phone:
Email:
Employer:
Occupation:
Employer Address:
City:
Zip:
Work Phone:

Whom may we thank for referring you?

Insurance Information

Person Financially Responsible:
Phone:
Do you have dental insurance?
Insurance Company Name:
Insured Social Security #:
Insured Birthdate:

Medical History

Dentist Name:
Physician Name:
Oral Surgeon Name:
Anemia?
Asthma?
Bone disorders?
Diabetes?
Endocrine problems?
Epilepsy?
Fainting / Dizziness?
Glaucoma?
Heart trouble?
Hepatitis?
HIV / AIDS?
Kidney Involvement?
Liver Involvement?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Rheumatic fever?
Tuberculosis?

Have tonsils and adenoids been removed? At what age?
List any drugs or medications now being taken. Give reasons:
List any allergies or drug sensitivity:

Dental History

Have there been any injuries to the face, mouth, or teeth?
Has the patient ever sucked a thumb or fingers?
What age?
Does the patient have any speech problems?
Have you been informed of any missing or extra permanent teeth?
Has an orthodontist been consulted previously?
Has the patient been diagnosed with sleep apnea?
What are you most interested in today?
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