Confidential Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
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Address:
*
City:
*
State:
*
Zip:
*
Home Phone:
*
Cell Phone:
*
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
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.
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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
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Birthdate:
*
Address:
*
City:
*
State:
*
Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
*
Home Phone:
*
Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security #:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Do you have dental coverage?
No
Yes
(IF YES, REQUIRED FIELDS AS NOTED BELOW)
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Policy Holder's Name:
*
Policy Holder's DOB:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
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)
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Policy Holder's Name:
*
Policy Holder's DOB:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
*
Insurance Company:
*
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
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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
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats?
No
Yes
*
Chipped or injured permanent teeth?
No
Yes
*
Teeth sensitive to hot or cold?
No
Yes
*
Previous root canal therapy?
No
Yes
*
Bad taste/mouth odor?
No
Yes
*
Previous periodontal (gum) treatment?
No
Yes
*
Abnormal swallowing (tongue thrust)?
No
Yes
*
Teeth that irritate tongue, cheek, lip, etc?
No
Yes
*
Numerous fillings?
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
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
*
Thumb or finger habit as a child?
No
Yes
*
Jaw Fractures, cysts, mouth infections?
No
Yes
*
Bleeding gums?
No
Yes
*
Other periodontal (gum) problems?
No
Yes
*
Frequent canker sores or cold sores?
No
Yes
*
Have wisdom teeth been removed?
No
Yes
*
Problems with food trapped between teeth?
No
Yes
*
Is all dental work completed at this time?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
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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
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
*
Has there been any change in the patient's general health within the last year?
No
Yes
*
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
*
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
List any 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
*
Damaged or artificial heart valves
No
Yes
*
Congenital Heart Defect
No
Yes
*
Heart Disease
No
Yes
*
Rheumatic Fever
No
Yes
*
Liver Disease / Jaundice / Hepatitis
No
Yes
*
Kidney Disease
No
Yes
*
Heart Attack/Stroke
No
Yes
*
Hemophilia
No
Yes
*
Hypertension/High Blood Pressure
No
Yes
*
Prolonged Bleeding/Transfusion
No
Yes
*
Anemia / Blood disorder
No
Yes
*
HIV/AIDS
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Arthritis / Joint problems
No
Yes
*
Diabetes
No
Yes
*
Growth Problems
No
Yes
*
Tuberculosis or Lung Disease
No
Yes
*
Pneumonia
No
Yes
*
Cancer
No
Yes
*
Family History of Cancer
No
Yes
*
Received Radiation Treatment
No
Yes
*
Thyroid / Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Metal Allergy
No
Yes
*
Nervous Disorders
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Seizures / Epilepsy / Neurological Disease
No
Yes
*
Treated for Emotional Problems
No
Yes
*
Asthma
No
Yes
*
Sexually transmitted disease
No
Yes
*
Take Bisphosphonates (Fosamax, Boniva)
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:
Height:
Weight:
School:
Grade:
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
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
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.