Confidential Patient Information
*
First Name:
Middle Initial:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Main Phone:
Cell Phone for Text Reminders:
Email for Appointment Reminders:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
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.
*
First Name:
Middle Initial:
*
Last Name:
*
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Main Phone:
Cell Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please complete insurance information below.
Insurance Company:
Member ID or Social Security #:
Group #:
Insured Birthdate:
Insurance Company Address:
Employer:
Occupation:
Dental History
Dentist Name:
Check-up Frequency:
Twice per year
Once per year
More than twice a year
Never
Emergencies only
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patients/parents main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
*
Speech problems/therapy?
No
Yes
*
Grind or clench teeth?
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
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
If yes, age oral habit stopped?
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats/ear infections?
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
*
Requires premedication?
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of last Physical:
Patient Health:
Good
Excellent
Fair
Poor
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
*
Rheumatic Fever
No
Yes
*
Tuberculosis/Lung Disease
No
Yes
*
Pneumonia
No
Yes
*
Liver Disease
No
Yes
*
Kidney Disease
No
Yes
*
Heart Attack/Stroke
No
Yes
*
Heart Disease
No
Yes
*
Congenital Heart Defect
No
Yes
*
Heart Murmur
No
Yes
*
Hemophilia
No
Yes
*
Hypertension/High Blood Pressure
No
Yes
*
Prolonged Bleeding/Transfusion
No
Yes
*
Anemia
No
Yes
*
HIV/AIDS
No
Yes
*
Hepatitis
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
*
Cancer
No
Yes
*
Family History of Cancer
No
Yes
*
Received Radiation Treatment
No
Yes
*
Growth Problems
No
Yes
*
Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Latex/Metal Allergy
No
Yes
*
Nervous Disorders
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Diabetes
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Asthma
No
Yes
*
Arthritis
No
Yes
*
Treated for Emotional Problems
No
Yes
*
Ever Been Hospitalized/Major Illness
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
School:
Grade:
Parent/Guardian 1 Name:
Parent/Guardian 2 Name:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
I affirm the accuracy of the above and have read the "Notice of Privacy Practices" policy available on the
CUENIN ORTHODONICS
website
.