All required (
*
) fields must be filled in before form can be submitted.
Patient Biographical Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
*
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:
*
Cell Phone:
2nd Phone:
*
Email:
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?
Responsible Party Information
Check if the patient is also the person who will be the Responsible Party.
*
First Name:
Middle Initial:
*
Last Name:
*
Birthdate:
*
Relationship to Patient:
Self
Mother
Father
Step Mother
Step Father
Guardian
Spouse
Other
*
Marital Status:
Single
Married
Separated
Divorced
*
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:
*
Years at Address?
1-2 years
2.1-2.9 years
3-3.9 years
4-5.9 years
6-9.9 years
10+ years
*
Own, Rent, or Other:
Own
Rent
Other
Previous Address (if less than 3 years)
Financial Party Information
Check if the Financial Party is also the Responsible Party.
*
First Name:
*
Last Name:
Social Security #:
*
Employer:
*
Occupation:
*
Length of Employment
Not Employed
0-11 mths
12-18 mths
19m-2 years -3-3.9 years
4-5.9 years
6-9.9 years
10+ years
*
Birthdate:
Name of Insurance Company:
Subscriber Name:
Subscriber Employer:
Subscriber ID#/SSN:
Subscriber DOB:
Secondary insurance benefit?
No
Yes
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
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.
*
Speech problems/therapy?
No
Yes
*
Clench or Grind Teeth?
No
Yes
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Discomfort from teeth or gums?
No
Yes
*
Pain, tenderness or noise in either jaw?
No
Yes
*
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats?
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
*
Requires premedication
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
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:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
*
Rheumatic Fever
No
Yes
*
Tuberculosis/Lung Disease
No
Yes
*
Pneumonia
No
Yes
*
Liver Disease
No
Yes
*
Kidney Disease
No
Yes
*
Heart Attack/Stroke
No
Yes
*
Heart Disease
No
Yes
*
Congenital Heart Defect
No
Yes
*
Heart Murmur
No
Yes
*
Hemophilia
No
Yes
*
Hypertension/High Blood Pressure
No
Yes
*
Prolonged Bleeding/Transfusion
No
Yes
*
Anemia
No
Yes
*
HIV/AIDS
No
Yes
*
Hepatitis
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
*
Cancer
No
Yes
*
Family History of Cancer
No
Yes
*
Received Radiation Treatment
No
Yes
*
Growth Problems
No
Yes
*
Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Latex/Metal Allergy
No
Yes
*
Nervous Disorders
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Diabetes
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Asthma
No
Yes
*
Arthritis
No
Yes
*
Treated for Emotional Problems
No
Yes
*
Ever Been Hospitalized
No
Yes
If any of the above medical questions were answered 'Yes' , please explain: