Patient Information

First Name:
Middle Initial:
Last Name:
Prefers to be Called:
Birthdate:
Gender:
Status:
Address:
City:
State:
Zip:
Home Phone:
Email:
Dentist Name:
Last Dental Visit:
Whom may we thank for referring you to our practice?
Favorite Hobby:
Other family members treated orthodontically?
Social Security #:
Employer:
Occupation:
Work Phone:
Length of Employment:

Spouse Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Person Responsible for Account (if other than above)

First Name:
Middle Initial:
Last Name:
Birthdate:
Telephone:
Social Security #:
Address:
City:
State:
Zip:
Employer:
Occupation:
Length of Employment:
Orthodontic Insurance Coverage?
Primary Orthodontic Insurance Company Name:
Secondary Orthodontic Insurance Company Name:

Health History

Medical History

Please check if the patient has, or has had...

Asthma?
If so, what medications(s)?
Convulsions/Epilepsy?
Diabetes?
Heart Murmur/Congenital heart defect?
Hepatitis or Liver Problems?
HIV+ or AIDS?
Joint Swelling or Arthritis?
Operations/Stays in hospital?
Prolonged Bleeding/Hemophilia?
Rheumatic Fever?
Tonsils/Adenoids Removed?
If so,when?
Tuberculosis?
Smoking?
List Allergies:
Describe patient's current physical health:

Dental History

Please check if the patient has, or has had...

Injuries to:
Thumb, finger or lip sucking habit(s)?
Mouth breathing when:
Missing or extra permanent teeth?
Any teeth removed by extraction?
If so, when:
Is there a tongue thrust problem?
Any clenching or grinding of teeth:
When opening or closing jaw to:
Been evaluated or had previous orthodontic treatment?
Frequent headaches?
If yes, how many per week?
Any muscle tenderness or stiffness in the:
Any previous treatment for TMJ or jaw joint problems?
If yes, please explain:
PLEASE LIST YOUR CHIEF CONCERN(S) AND WHAT YOU WOULD LIKE TREATMENT TO ACCOMPLISH:
Signature:
Date: