Patient Information
First Name:
Middle Initial:
Last Name:
Prefers to be Called:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Home Phone:
Patient's Dentist:
Last Dental Visit:
Whom may we thank for referring you to our practice?
Other family members treated orthodontically?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Status:
Single
Married
Divorced
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Home Phone:
Social Security #:
Employer:
Length of Employment:
Spouse Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Orthodontic Insurance Coverage?
No
Yes
Primary Insurance
Primary Insured:
Insured Employer:
Orthodontic Insurance Company Name:
Secondaryd Insurance
Secondary Insured:
Insured Employer:
Orthodontic Insurance Company Name:
Health History
Medical History
Please check if the patient has, or has had...
Asthma?
No
Yes
If so, what medications(s)?
Convulsions/Epilepsy?
No
Yes
Diabetes?
No
Yes
Heart Murmur/Congenital heart defect?
No
Yes
Hepatitis or Liver Problems?
No
Yes
HIV+ or AIDS?
No
Yes
Joint Swelling or Arthritis?
No
Yes
Operations/Stays in hospital?
No
Yes
Prolonged Bleeding/Hemophilia?
No
Yes
Rheumatic Fever?
No
Yes
Tonsils/Adenoids Removed?
No
Yes
If so,when?
Tuberculosis?
No
Yes
Smoking?
No
Yes
List Allergies:
Describe patient's current physical health:
Good
Fair
Poor
Dental History
Please check if the patient has, or has had...
Injuries to:
Face
Mouth
Teeth
Chin
Thumb, finger or lip sucking habit(s)?
No
Yes
Continued
Discontinued
Mouth breathing when:
Asleep
Awake
Missing or extra permanent teeth?
No
Yes
Any teeth removed by extraction?
No
Yes
If so, when:
Is there a tongue thrust problem?
No
Yes
Any clenching or grinding of teeth:
Opening or closing
Night
Both
When opening or closing jaw to:
Pain
Popping
Locking
Been evaluated or had previous orthodontic treatment?
No
Yes
Frequent headaches?
No
Yes
If yes, how many per week?
Morning
Afternoon
Any muscle tenderness or stiffness in the:
Jaw
Neck
Any previous treatment for TMJ or jaw joint problems?
No
Yes
If yes, please explain:
PLEASE LIST YOUR CHIEF CONCERN(S) AND WHAT YOU WOULD LIKE TREATMENT TO ACCOMPLISH:
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Signature:
Date: