Confidential Patient Information

First Name:
Middle Name:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
Please list the names of family currently in the practice:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Name:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Name:
Last Name:
Relationship to Patient:
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental Insurance Information

If Policy Holder is not the Responsible Party, please list Address and Date of Birth

Policy Holder's Address:
Policy Holder's D.O.B.:

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # (if not avalable give SSN):
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID # (if not avalable give SSN):
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
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?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Chipped or injured permanent teeth?
Previous periodontal (gum) treatment?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Metal Allergy
Milk Allergy
Other:
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Heart Attack/Stroke
Hemophilia
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Arthritis / Joint problems
Large Tonsils
Bone fractures/trauma to face/jaw
Prosthetic joints
Diabetes
Growth Problems
Cancer
Received Radiation Treatment
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation for Orthodontic Treatment

Teeth - If your teeth could be changed, how would you like them to change?
Face - If your facial appearance could be changed, what would you change?
Symptoms - If you want to reduce pain or discomfort, please be specific about its location.

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
I have received notice of privacy practices.
Signature (Parent's signature if minor):
Update (date & inital)