Confidential Patient Information
First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender at birth:
Pronoun:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
If patient is a minor, give parent's or guardian's name:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Parent/Guardian 1 First Name:
Middle Initial:
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:
Cell Phone:
Parent/Guardian 2 First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
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's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the Patient need to premedicate prior to dental visit?
No
Yes
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?
No
Yes
Clench or Grind Teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Bad taste/mouth odor?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw Fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Have wisdom teeth been removed?
No
Yes
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Do you clench your teeth?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Does your bite feel uncomfortable or unusual?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
Metal Allergy
No
Yes
Other:
No
Yes
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
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
Large Tonsils
No
Yes
Sinus trouble
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Prosthetic joints
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Thyroid / Endocrine Problems
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Asthma
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Signature:
Date: