Confidential Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Complete Address:
Main Phone:
2nd/Cell Phone:
Email:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
How did you hear about our practice or whom may we thank for referring you?
Dentist
Internet Search
Insurance
Friend
Social Media
Other
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Complete Address:
Email of Responsible Party (Even if the same):
Main Phone:
2nd/Cell Phone:
Social Security #:
Dental Insurance Information
Do you have dental insurance?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Dental History
Dentist Name:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Does the patient have any of the following?
No
Yes
If yes, please select those that apply.
Speech problems/therapy?
Yes
Tonsils/Adenoids Removed?
Yes
Clench or Grind Teeth?
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
Yes
Injury to face, jaw, teeth or mouth?
Yes
Mouth breathing?
Yes
Snores during sleep?
Yes
Any missing or extra permanent teeth?
Yes
Apprehensive about dental care?
Yes
TMJ Problems
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Does the patient take medications?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug sensitivites (metal, latex, medications, food)?
No
Yes
If yes, please list below:
Heart or joint condition that requires you to take antibiotics before dental treatment (murmur, congenital defect, damged valves, prosthetic valves or joints)?
No
Yes
Does the patient have any medical conditions?
No
Yes
If yes, please explain below:
Patient Motivation for Orthodontic Treatment
Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by listing them in the box below:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If so, when:
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I understand that where appropriate, credit bureau reports may be obtained.