Confidential Patient Information

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

If patient is a minor, please provide name(s) of parent(s)/guardian(s):
Whom may we thank for referring you to our office?
School:
Grade:
Please list names, dates of birth, and ages of children/siblings:
Please list some hobbies or interests:

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Residence:
City:
State:
Zip:
Mailing Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Cell/Other Phone:
Email Address:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Spouse or Other Parent/Guardian First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Dental Insurance Information

Insured's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Policy Group Number:
Insurance Company Name:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete the following)
Insured's Name:
Date of Birth:
Social Security #:
Policy Holder's Employer:
Policy Group Number:
Insurance Company Name:
Insurance Company Phone:

Emergency Information

Emergency Contact (nearest you):
Relationship to Patient:
Address:
Phone:

Medical History

Physician Name:
Phone:
Date of Last Visit:
Address:
City:
State:
Zip:

Are you in good health?
Do you have a history of a major illness?
Have you had any operations or been hospitalized?
Have you ever been involved in a serious accident?
Have you ever smoked or chewed tobacco?
Please list any medications currently being taken by the patient (include over-the-counter):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Latex?
Metal?
Please list any other drug allergies or sensitivities that the patient may have:
Have any tonsils or adenoids been removed?
Female patients only:
Are you pregnant?
Are you nursing?
Children only:
Has patient reached puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed?
If any of the above medical questions were answered 'Yes' , please explain:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal Bleeding/Hemophilia
Anemia
Arthritis
Asthma
Bone Disorders
Bronchitis
Cancer
Congenital Heart Defect
Diabetes
Developmental Disorder
Dizziness
Endocrine Disorder
Epilepsy/Convulsions/Seizures
Glaucoma
Growth Disorder
Kidney Disease
Hay Fever/Allergies
Heart Attack/Stroke
Heart Murmur
Heart Problems
Hepatitis/Jaundice
Herpes/Cold Sores
High/Low Blood Pressure
HIV+/AIDS?
Leukemia
Liver Disease
Lung/Respiratory Problems
Migraines/Severe Headaches
Nervous Disorders
Pneumonia
Prolonged Bleeding
Psychiatric Problems
Radiation/Chemotherapy
Rheumatic/Scarlet Fever
Sexually Transmitted Disease
Sinus Problems
Stomach Trouble/Ulcers
Thyroid Problems
Tuberculosis
Are there any other medical conditions we have not discussed that you feel we should be aware of?

Dental History

General Dentist:
Phone:
Date of most recent dental exam/cleaning/x-rays:
What are the main concerns you would like Orthodontics to address?
Have you ever had or been evaluated for Orthodontic treatment?
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to denstistry?
Have you ever lost or chipped any teeth?
Have you ever been informed of any missing or extra teeth?
Have there been any injuries to face, mouth, or teeth?
Is any part of your mouth sensitive to temperature?
Is any part of your mouth sensitive to pressure?
Do your gums bleed when you brush?
Are you aware of your jaw joint clicking or popping (TMJ/TMD)?
Are you aware of clenching/grinding of your teeth?
Do you have "tension" headaches?
Have you ever experienced chronic ringing in your ears?
Do you have any type of thumb or tongue habit?
Do you have any speech problems?
Are you a mouth breather?
Has anyone in your family received orthodontic treatment?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware that some appointments will be during school/work hours?
If patient under 18:
Mom's Height:
Dad's Height:
If any of the above dental questions were answered 'Yes', please explain:
Patient (Parent/Guardian if minor) E-Signature: