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
Primary Contact Phone:
Address:
City:
State:
Zip:
Parent 1 First Name:
Last Name:
Employer:
Occupation:
Contact Email:
Address (if different):
City:
State:
Zip:
Parent 2 First Name:
Last Name:
Employer:
Occupation:
Email:
Address (if different):
City:
State:
Zip:
Parent Status:
Single
Married
Widowed
Separated
Divorced
Patient's School:
Other Family Members treated?
What are the patient's interests (hobbies, sports, musical instruments)?
Do you have dental insurance?
Please provide dental insurance card(s) to the front desk
No
Yes
Name of Subscriber:
Birthday of Subscriber:
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
Name of Subscriber:
Birthday of Subscriber:
Name of Dental Insurance Company:
Subscriber/Member ID or SS#:
Group Number:
How Did You Hear About Us?
Please check all that apply and select the primary reason. Thank you!
Direct Referrals:
Dentist
Family Member
Friend/Co-Worker
Our Staff
Community:
Building Sign
Sports Team/Sponsorship
School Program/Folder
Online:
Website
Facebook
Instagram
Google
Miscellaneous:
In-network Insurance
Other
Main Reason:
Dentist
Family Member
Friend/Co-Worker
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 the patient is in good health?
No
Yes
If no, please explain:
Please select 'Yes' for any of the following for which the patient has 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
Migraines
No
Yes
If 'Yes', please explain:
Has the patient had their tonsils/adenoids removed?
No
Yes
If so, at what age?
Please list any drugs or medications:
Latex Allergy?
No
Yes
Does the patient require antibiotic pre-medication before dental procedures?
No
Yes
Female Patients:
Is the patient pregnant or anticipate she may be?
No
Yes
Any other medical issues not addressed above?
Recognizing that successful treatment greatly depends upon the patient's cooperation in following instructions, keeping appointments, and maintaining oral hygiene, do you expect any restrictions or problems that may be encountered during treatment?
Dental History
Dentist:
Date of Last Checkup/Cleaning:
How often does the patient brush their teeth?
Does the patient floss regularly?
No
Yes
Have any teeth been injured due to an accident or fall?
No
Yes
If yes, please explain:
Does the patient have any sensitivity or discomfort from their:
Gums
Teeth
Bite
Please explain:
Clench or grind teeth?
No
Yes
Speech Problems?
No
Yes
Finger sucking?
No
Yes
Mouth breathe/snore?
No
Yes
Has the patient had any previous orthodontic work?
No
Yes
If yes, at what age?
By whom?
Has the patient had any primary (baby) or permanent teeth removed?
No
Yes
Any clicking/popping/pain in joints?
No
Yes
Any other dental issues not addressed above?
Smile and Treatment Analysis
What is the patient's or parent's primary concern?
Do you feel the teeth are:
Spaced apart?
Crowded/Overlapping?
Sticking out too far?
"Gummy" smile?
Oddly shaped or sized teeth?
Are you aware of any bullying due to the appearance of the teeth?
No
Yes
Any other orthodontic concerns you'd like to discuss?
Patient's attitude toward treatment?
Excited
Neutral, but will cooperate
Not Motivated
I have read and understood this questionnaire and answered to the best of my knowledge.
I will not hold my orthodontist or staff responsible for any errors or omissions. If there are any changes to the patient's medical or dental history, I will alert the practice.