Confidential Patient Information
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First Name:
Middle Initial:
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Last Name:
Nickname:
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Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
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Gender:
Male
Female
Other
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Address:
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City:
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State:
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Zip:
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Main Phone:
Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
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First Name:
Middle Initial:
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Last Name:
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Birthdate is not in correct format (mm/dd/yyyy)
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
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Address:
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City:
*
State:
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Zip:
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Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone:
Insurance Information
Orthodontic Insurance Carrier:
Policy Holder Name:
Policy Holder SSN:
Policy Holder Date of Birth:
Policy Holder Employer:
Second Insurance (if applicable, dual coverage)
Orthodontic Insurance Carrier:
Policy Holder Name:
Policy Holder SSN:
Policy Holder Date of Birth:
Policy Holder Employer:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
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.
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Apprehensive about dental care?
No
Yes
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Brush teeth daily?
No
Yes
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Clench or grind teeth?
No
Yes
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Discomfort from teeth or gums?
No
Yes
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Floss teeth daily?
No
Yes
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Fluoride treatments?
No
Yes
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Frequently chew gum?
No
Yes
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Frequent headaches?
No
Yes
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Frequent sore throats?
No
Yes
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Injury to face, jaw, teeth, or mouth?
No
Yes
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Missing or extra permanent teeth?
No
Yes
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Mouth breathing?
No
Yes
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Neck or shoulder pain?
No
Yes
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Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
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Pain, tenderness, or noise in either jaw?
No
Yes
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Requires premedication?
No
Yes
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Snores during sleep?
No
Yes
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Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other 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.
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Anemia or blood disorder?
No
Yes
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Arthritis or joint problems?
No
Yes
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Asthma?
No
Yes
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Bisphosphonates (Fosamax, Boniva)?
No
Yes
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Bone disorders or loss?
No
Yes
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Cancer?
No
Yes
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Cancer in family history?
No
Yes
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Diabetes?
No
Yes
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Emotional problems treatment?
No
Yes
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Endocrine problems?
No
Yes
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Growth problems?
No
Yes
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Handicaps or disabilities?
No
Yes
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Heart attack or stroke?
No
Yes
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Heart defect (congenital)?
No
Yes
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Heart disease?
No
Yes
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Heart murmur?
No
Yes
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Hemophilia?
No
Yes
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Hepatitis?
No
Yes
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High blood pressure or hypertension?
No
Yes
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HIV or AIDS?
No
Yes
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Hormone therapy?
No
Yes
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Ever been hospitalized?
No
Yes
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Kidney disease?
No
Yes
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Latex or Metal Allergy?
No
Yes
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Liver disease, jaundice, or hepatitis?
No
Yes
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Nervous disorders?
No
Yes
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Pneumonia?
No
Yes
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Prolonged bleeding or transfusion?
No
Yes
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Radiation treatment?
No
Yes
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Rheumatic fever?
No
Yes
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Seizures, epilepsy, or neurological disease?
No
Yes
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Tonsils or adenoids removed?
No
Yes
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Tuberculosis or lung disease?
No
Yes
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:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No