Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Home/Cell Phone:
Address:
City:
State:
Zip:

Father's First Name:
Last Name:
Father's Employer:
Address (if different):
City:
State:
Zip:
Mother's First Name:
Last Name:
Mother's Employer:
Address (if different):
City:
State:
Zip:

Parent is:
Emergency Contact:
Phone:
Patient's School:

Other Family Members treated?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Do you have dental insurance? Please present dental insurance card(s) to the front desk

How Did You Hear About Us?

Please check all the ways you heard about us and select the main reason. Thank you!
Direct Referrals:
Community:
Online:
Miscellaneous:

Main Reason:

Medical History

Physician Name:
Do you feel as though the patient is in good health?
If no, please explain:
Please select 'Yes' for any of the following for which the patient has been diagnosed or treated:
Diabetes
Asthma
Allergies
Rheumatic Fever
Heart Trouble
Epilepsy
Cancer
Bleeding Disorders
Depression
Anemia
Seizures
ADD/ADHD
HIV/AIDS
Dizziness/Fainting
Migraines
Hip/Joint Replacement
If any of the above medical questions were answered 'Yes', please explain:
Have your tonsils and adenoids been removed? If so, at what age?
Is the patient currently or has taken bisphosphonate drugs such as Zometa, Fosamax, Boniva, etc. for bone disorders or cancer?
If yes, please explain:
Please list any drugs or medications:
Latex Allergy?
Does the patient take antibiotic pre-medication before any dental procedures?
Female Patients: Are you pregnant or anticipating becoming pregnant?
Any other medical issues not addressed above?
Realizing that successful treatment greatly depends upon the patient's complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during orthodontic treatment?

Dental History

Dentist Name:
Date of Last Checkup/Cleaning:
How often do they brush their teeth?
How often do they floss?
Has the patient ever been treated for periodontal disease or have a history of periodontal problems?
If yes, please explain:
Have any teeth been injured due to accidents or falls?
If yes, please explain:
Has the patient had any severe head or face injuries?
If yes, please explain:
Has the patient experienced any sensitivity or discomfort from:
Please explain:
Clench or grind teeth?
Speech Problems?
Suck Thumb or Fingers?
Mouth breather?
Has the patient had any previous orthodontic work? If yes, at what age (approximate)?
By whom?
Has the patient had any primary (baby) or permanent teeth removed?
Clicking or popping in jaw joints?
Describe:
Pain in jaw joints?
Describe:
Ever been treated for "TMJ" or "TMD" problems?
Describe:
Any other dental issues not addressed above?

Smile Analysis

What is the patient's (or parent's) primary concern?
Do you feel the teeth are:
Are there any other orthodontic issues not listed above that you wish to discuss?
Patient's attitude toward treatment?