Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Preferred Name (Nickname):
Birthdate:
Clinical Gender:
Male
Female
Gender Identity (if different):
He/His/His/Himself
She/Her/Hers/Herself
They/Their/Theirs/Themself
Phone:
Email:
Address:
City:
State:
Zip:
Employer:
Occupation:
Emergency Contact:
Phone:
Other Family Members treated?
Do you have dental insurance?
Please present dental insurance card(s) to the front desk
No
Yes
Name of Subscriber (if not yourself):
Birthday of Subscriber (if not yourself):
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
Name of Subscriber (if not yourself):
Birthday of Subscriber (if not yourself):
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
How Did You Hear About Us?
Please check all the ways you heard about us and select the main reason. Thank you!
Direct Referrals:
Dentist/Hygienist
Family Member
Friends/Co-Workers
Our Staff
Community:
Building Sign
Sports Teams/Sponsorship
School Program/Folder
Online:
Website
Facebook
Instagram
Google
Miscellaneous:
In-network Insurance
Other
Main Reason:
Dentist/Hygienist
Family Member
Friends/Co-Workers
Our Staff
Website
Facebook
Instagram
Google
Building Sign
Sports Teams/Sponsorship
School Program/Folder
In-network Insurance
Other
Medical History
Physician Name:
Do you feel as though you are in good health?
No
Yes
If no, please explain:
Do you smoke?
No
Yes
Please select 'Yes' for any of the following for which you have been diagnosed or treated:
Diabetes
No
Yes
Asthma
No
Yes
Allergies
No
Yes
Rheumatic Fever
No
Yes
Heart Issues
No
Yes
Cancer
No
Yes
Bleeding Disorders
No
Yes
Depression
No
Yes
Anemia
No
Yes
Seizures/Epilepsy
No
Yes
ADD/ADHD
No
Yes
HIV/AIDS
No
Yes
Dizziness/Fainting
No
Yes
Migraines
No
Yes
Joint Replacement
No
Yes
If any of the above medical questions were answered 'Yes', please explain:
Have your tonsils and adenoids been removed?
No
Yes
If so, at what age?
Are you currently or have you taken bisphosphonate drugs (Zometa, Fosamax, Boniva, etc)?
No
Yes
Please list any drugs or medications you are taking:
Latex Allergy?
No
Yes
Do you take antibiotic pre-medication before any dental procedures?
No
Yes
Female Patients:
Are you pregnant or anticipating becoming pregnant?
No
Yes
Any other medical issues not addressed above?
Dental History
Dentist Name:
Date of Last Checkup/Cleaning:
Have you ever been treated for periodontal disease or have a history of periodontal problems?
No
Yes
If yes, please explain:
Have any teeth been injured due to accidents or falls?
No
Yes
If yes, please explain:
Have you experienced any sensitivity or discomfort from:
Gums
Teeth
Bite
Please explain:
Clench or grind teeth?
No
Yes
Mouth breather?
No
Yes
Have you had any previous orthodontic work?
No
Yes
If yes, at what age (approximate)?
By whom?
Do you have any jaw concerns/symptoms (TMJ/TMD)?
No
Yes
Explain:
Any other dental issues not addressed above?
Smile Analysis
What is your primary concern?
Do you feel the teeth are:
Spaced apart?
Crowded/Overlapped?
Stick out too far?
"Gummy" smile?
Don't show enough teeth when smiling?
Oddly shaped or sized teeth?
Do you prefer to smile without showing your teeth?
No
Yes
Any other orthodontic concerns you'd like to discuss?
I have read and understand the above questions.
I will not hold my orthodontist or staff responsible for any errors or omissions. If there are any changes to my medical or dental history, I will alert the practice.