Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Mailing Address:
City:
State:
Zip:
Physical Address:
City:
State:
Zip:
How long at this address?
Home Phone:
Email:
Family Dentist:
Last Visit Date:
Primary Care Physician:
Whom can we thank for your referral?
Other family members seen?
Responsible Party Information
Are you planning on using a Health Savings or Flex Spending Account for orthodontics treatment?
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security Number:
Main Phone:
Cell Phone:
Employer:
Length of Employment:
Work Phone:
Other Spouse or Partner's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Social Security Number:
Main Phone:
Cell Phone:
Employer:
Length of Employment:
Work Phone:
Dental Insurance Information
Do you have orthodontic insurance?
No
Yes
(If yes, complete information below)
Insurance Company Name:
Policy Holder's Name:
Group Number:
Policy Holder's ID or Social Security Number:
Policy Holder's Birthdate:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Dental History
How would you rate your smile? 1 (I don't know where to start) to 10 (I love it):
One area that you would like to change with your smile?
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the patient need to premedicate with antibiotics prior to dental visit?
No
Yes
Any injuries/accidents to face or teeth?
No
Yes
Describe
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Difficulty chewing?
No
Yes
Difficulty swallowing?
No
Yes
Difficulty speaking?
No
Yes
Thumb or finger sucking?
No
Yes
Mouth breathing?
No
Yes
Snoring at night?
No
Yes
Grinding teeth at night?
No
Yes
Popping/clicking in the jaw joints?
No
Yes
Any gum tissue concerns or previous treatments?
No
Yes
Any additional dental information?
Medical History
Are you on any medications? If yes, please list:
Are you taking/have taken osteoporosis medication? If yes, please list:
Are you allergic to any medications? If yes, please list:
Are you allergic to Latex?
No
Yes
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?
No
Yes
Have tonsils or adenoids been removed?
No
Yes
Arthritis?
No
Yes
Artificial limbs or joint replacements?
No
Yes
Asthma?
No
Yes
Blood transfusion?
No
Yes
Cancer?
No
Yes
Chronic ear infections?
No
Yes
Diabetes?
No
Yes
Dizziness?
No
Yes
Frequent headaches?
No
Yes
Frequent neck or backaches?
No
Yes
Ringing in the ears?
No
Yes
Heart murmur?
No
Yes
Hepatitis?
No
Yes
HIV / AIDS?
No
Yes
Rheumatic / Scarlet fever?
No
Yes
Tuberculosis?
No
Yes
Smoke or use nicotine products?
No
Yes
Other condition or problem that you think we should know about? Please describe:
Acknowledgement of Receipt of Notice of Privacy Practices
I,
, have received a copy of this office's Notice of Privacy Practices.
Pediatric Sleep Questionnaire
Please fill this form as accurately and honestly as possible. In our practice we are very interested in our patients' overall health. Orthodontic treatment can be an important part of managing the health problems caused by sleep and breathing disorders.
While sleeping does your child snore?
No
Yes
While sleeping does your child have "heavy" or loud breathing?
No
Yes
While sleeping does your child have trouble breathing, or struggle to breathe?
No
Yes
Have you ever seen your child stop breathing during the night?
No
Yes
Does your child occasionally (check all that apply):
Wet the bed?
Sleepwalk?
Have night terrors?
Does your child tend to breathe through the mouth during the day?
No
Yes
Does your child have a dry mouth on waking up in the morning?
No
Yes
Does your child wake up unrefreshed in the morning?
No
Yes
Does your child wake up with a headache in the morning?
No
Yes
Does your child have frequent sore throats or nasal congestion?
No
Yes
Is it hard to wake your child up in the morning?
No
Yes
Does your child have a problem with sleepiness during the day?
No
Yes
Has a teacher commented that your child appears sleepy during the day?
No
Yes
Did your child stop growing at a normal rate at any time since birth?
No
Yes
Is your child overweight?
No
Yes
Are you concerned about your child's sleep?
No
Yes
Child often does not seem to listen when spoken to directly.
No
Yes
Child often has difficulty organizing tasks and activities.
No
Yes
Child often is easily distracted by extraneous stimuli.
No
Yes
Child often fidgets with hands or feet or squirms in seat.
No
Yes
Child often is "on the go" or often acts as if "driven by a motor".
No
Yes
Child often interrupts or intrudes on others (butts into conversations or games).
No
Yes
I have completed the above information.
E-Signature:
Date: