Patient Information
Patient's First Name:
Middle Initial:
Patient's Last Name:
Birthdate:
School (if applicable):
Who is the patient's General Dentist? (if none, type N/A)
Do you have any friends or family that attend JT Orthodontics? (If so, please list their names)
Billing Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Email:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Dental Insurance Information
Primary Dental Insurance Information
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's SSN:
Insurance Company Name:
Insurance Company Phone:
Policy Holder's ID:
Group or Local Number:
Secondary Dental Insurance Information
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's SSN:
Insurance Company Name:
Insurance Company Phone:
Policy Holder's ID:
Group or Local Number:
Medical History
Patient's Height:
Patient's Weight:
Who is the patient's Primary Care Physician?
Primary Care Physician's phone number:
Check all medical concerns that appy to the patient:
No Medical Concerns
Abnormal Bleeding
ADHD (Attention Deficit Hyperactivity Disorder)
Anemia
Arthritis
Artificial Bones, Joints, or Valves
Asthma
Autism Spectrum
Blood Transfusion
Cancer and/or Chemotherapy
Congenital Heart Defects
Diabetes
Difficulty Breathing
Drug Abuse
Emphysema
Epilepsy, Seizures, and/or Fainting
Fever blisters, Cold sores, or Herpes Simplex
Glaucoma
Heart Attack/ Stroke
Heart Murmur
Heart Surgery/ Pace Maker
Hemophilia
Hepatitis
High Blood Pressure
History of Psychiatric Issues
HIV positive, or AIDS
Hospitalized for any reason
Kidney Problems
Low Blood Pressure
Mitral Valve Prolapse
Radiation Treatment
Rheumatic Fever
Scarlet Fever
Severe and Frequent Headaches
Shingles
Sickle Cell Disease
Sinus Problems
Sleep Apnea/ Sleep Disorder
Traits
Tuberculosis
Other medical concern (please list below):
Is the patient allergic to any of the follow? (Check all that apply)
No Allergies
Any Metals
Aspirin
Codeine
Dental Anesthetics
Erythromycin
Latex
Penicillin
Plastics
Tetracycline
Other allergies (indicate below)
Please list any medications the patient is currently taking (include non-prescription):
Tobacco Use:
Current
Former
Never
Is the patient currently pregnant or nursing?
Yes
No
Check all sleep concerns that apply (Must check at least one/ these apply to you or your child):
No sleep or behavioral concerns
Patient fidgets
Snoring
The patient breathes through his/her mouth during the day
The patient feels excessively sleepy during the day
The patient frequently wakes up with headaches
The patient has been advised that they are overweight
The patient has been advised that they are underweight
The patient has completed a sleep study in the past
The patient is easily distracted
The patient still wets the bed
The patient stops breathing during the night
Dental History
What concerns do you have in regard to the patient's teeth/smile?
Check all dental history and concerns that apply (Must check at least one):
No dental concerns
Speech issues or difficulty
Currently or previously sucked fingers or thumbs
I have been informed of missing teeth
Clench or grinds teeth
I have been informed of extra teeth
I am mainly interested in treatment for cosmetic reasons
Chipped Teeth
I need space maintenance
Trauma to mouth or face
I do not want braces
Any tooth extractions
Difficulty chewing or swallowing
Pain or clicking when closing mouth
Previous orthodontic treatment
I have had a previous orthodontic consultation
Emergency Contact Information
First and Last Name:
Phone Number:
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.