Confidential Patient Information
First Name:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
If patient is a minor, does the patient live with both parents?
No
Yes
If no, with whom does the patient live?
Main Phone:
Email:
How did you hear about us?
Main orthodontic concern:
Has the patient had an orthodontic consult or treatment:
List any sports, hobbies, or musical instruments played:
Number of children in family?
Ages of children in family?
Responsible Party Information
Check if the patient is also the person who will be the responsible party for treatment.
Does this person have legal authority to make medical decisions for this patient?
No
Yes
First Name:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
Spouse or Other Parent's Information
Spouse or Other Parent's First Name:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Main Phone:
Email:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder Date of Birth:
Insurance Company Name:
Subscriber ID:
Group Number:
Group Name:
Insurance Company Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder Date of Birth:
Insurance Company Name:
Subscriber ID:
Group Number:
Group Name:
Insurance Company Phone:
Dental History
Dentist Name:
Last Dental Visit:
Is all dental work completed?
No
Yes
Does the Patient need to premedicate prior to dental visit?
No
Yes
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 or therapy?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Injury to teeth?
No
Yes
Tooth pain or sensitivity?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Any missing teeth?
No
Yes
Any extra teeth?
No
Yes
Any impacted teeth?
No
Yes
Any extraction of primary or permanent teeth?
No
Yes
Bleeding gums?
No
Yes
Other periodontal (gum) problems?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
TMJ History
Have you had a TMJ screening?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Clench or grind teeth?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Neck or shoulder pain?
No
Yes
Do you have a history of joint problems?
No
Yes
Has your jaw ever locked?
No
Yes
Do you notice any clicking or popping in your jaw joint?
No
Yes
Trauma to chin or jaw?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Do you use a night guard?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Airway/Sleep History
Sleep apnea?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Sinus problems?
No
Yes
Bed wetting?
No
Yes
Restless sleep?
No
Yes
Excess sweat while you sleep?
No
Yes
Seasonal allergies?
No
Yes
Consultation with ear, nose, and throat doctor?
No
Yes
Anyone in the family with sleep apnea?
No
Yes
Removal of tonsils and/or adenoids?
No
Yes
If any of the above Airway/Sleep questions were answered 'Yes', please explain:
Medical History
Take Bisphosphonates (Fosamax, Boniva)?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex?
No
Yes
Acetaminophen (Tylenol)?
No
Yes
Ibuprofen (Advil, Motrin)?
No
Yes
Naproxen (Aleve)?
No
Yes
Local anesthetics?
No
Yes
Nickel/Metal?
No
Yes
Penicillin or other antibiotics?
No
Yes
Sulfa drugs?
No
Yes
Other?
No
Yes
Please list any other drug allergies or sensitivities 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?
No
Yes
Heart defect (congenital)?
No
Yes
Damaged or aritificial heart valves?
No
Yes
Rheumatic fever?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Kidney disease?
No
Yes
Heart attack or stroke?
No
Yes
Hemophilia/Abnormal bleeding?
No
Yes
High blood pressure or hypertension?
No
Yes
Anemia or blood disorder?
No
Yes
HIV or AIDS?
No
Yes
Arthritis or joint problems?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Diabetes?
No
Yes
Growth problems?
No
Yes
Tuberculosis or lung disease?
No
Yes
Cancer treatment?
No
Yes
Received radiation treatment?
No
Yes
Thyroid or endocrine problems?
No
Yes
Stomach ulcer or hyperacidity?
No
Yes
Hormone therapy?
No
Yes
Nervous disorders, anxiety, depression?
No
Yes
ADHD?
No
Yes
Sickle cell anemia?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Asthma?
No
Yes
Fever blisters/herpes?
No
Yes
Low blood pressure?
No
Yes
Heart surgery/pacemaker?
No
Yes
Mitral valve prolapse?
No
Yes
Bone disorder/bone loss?
No
Yes
Lyme disease/babesia?
No
Yes
FEMALES: Are you pregnant?
No
Yes
Girls: Has menstration started?
No
Yes
Boys: Has voice changed?
No
Yes
List any medical issues not listed above the patient may have:
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 in the event of divorced, separated, or never married parents, if another natural/adoptive parent or legal guardian is required to give legal medical consent for the patient, it is my responsibility to inform the practice in writing prior to starting orthodontic treatment.