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:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
Insurance Company Name:
Employer:
Subscriber ID:
Insurance Company Phone:

Dental History

Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
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.
Clench or grind teeth?
Injury to face, jaw, teeth, or mouth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Requires premedication for dental procedures?
Snores during sleep?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

Please list any medications currently being taken by the patient (include non-prescription):
Please 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.
Asthma?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Hormone therapy?
Latex/Metal Allergy?
Radiation treatment?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
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:
Patient Height:
Patient Weight:
School:
Grade:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?