Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:

What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Email:
Main Phone:
Main Phone Type:
Social Security Number:
Employer:
Occupation:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Main Phone:
Main Phone Type:
Employer:
Occupation:

The above parties:

If divorced, which of the above parties is the primary custodial guardian?

If divorced, does the primary guardian give us permission to discuss treatment/financial information with the other party?

Name any other parties the custodial guardian will allow us to share information with:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name:
Address:
Relationship to Patient:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
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.
Abnormal swallowing (tongue thrust)?
Apprehensive about dental care?
Bad taste or mouth odor?
Bleeding gums?
Brush teeth daily?
Chipped or injured permanent teeth?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Fluoride treatments?
Frequent canker sores or cold sores?
Frequently chew gum?
Frequent headaches?
Frequent sore throats?
Have wisdom teeth been removed?
Injury to face, jaw, teeth, or mouth?
Jaw fractures, cysts, or mouth infections?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Numerous fillings?
Oral habits (thumb or finger sucking, lip or nail biting)?
Other periodontal (gum) problems?
Pain, tenderness, or noise in either jaw?
Previous periodontal (gum) treatment?
Previous root canal therapy?
Problems with food trapped between teeth?
Snores during sleep?
Speech problems or therapy?
Teeth sensitive to hot or cold?
Teeth that irritate tongue, cheek, lip, etc?
Thumb or finger habit as a child?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:

Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
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.
Angina?
Anemia or blood disorder?
Arteriosclerosis?
Arthritis or joint problems?
Asthma?
Bed wetting?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Bone fractures or trauma to face or jaw?
Cancer?
Cancer in family history?
Chronic fatigue?
Diabetes?
Emotional problems treatment?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Heart valves are damaged or artificial?
Hemophilia?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Low blood pressure?
Nervous disorders?
Persistent cough?
Persistent swollen neck glands?
Pneumonia?
Prolonged bleeding or transfusion?
Prosthetic joints?
Radiation treatment?
Respiratory problems or emphysema
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Sexually transmitted disease?
Sinus trouble?
Stomach ulcer or hyperacidity?
Substance abuse problem (past or present)?
Thyroid or endocrine problems?
Tonsils enlarged?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation For Orthodontic Treatment

Patients often request changes to their appearence and/or relief from pain or discomfort. Please help us to understand your concerns by selecting the best answers to the following questions. Be as specific as possible. If you are unsure or indifferent to a question, leave it blank.

If your teeth could be changed, how would you like them to change?

Straighten front teeth:
Straighten back teeth:
Move upper teeth:
Move lower teeth:
Eliminate spaces between teeth:
Eliminate crowding of teeth:
Make line of upper teeth more level:
Other:

If your facial appearance could be changed, what would you change?

Move upper lip:
Move lower lip:
When smiling, show my teeth:
When smiling, show my gums:
Make my nose:
Move chin depth:
Move chin laterally:
When closing my lips, reduce strain in my:
When my teeth touch, make my lips:
Get rid of sag under lower jaw:
Other:

If you want to reduce pain or discomfort, please be specific about its location. Select the right side, left side, or both if they apply.

My teeth:
My sinuses:
In front of ears:
Below ears:
Above ears:
In my ears:
My temples:
My eyes:
My neck:
My shoulders:
My jaw joints:
Other:

No patients under age 18 will be examined unless accompanied by a parent/legal guardian.

Signature of legal guardian responsible for account (or signed by patient age 18 and older).