Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname/Preferred Name:
Birthdate:
Gender:
Male
Female
Other
If the patient is a child, what school do they attend:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Please list the names of any friends or family in our practice?
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Occupation:
Work Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Occupation:
Work Phone:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID:
Policy Holder's Employer:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber ID:
Policy Holder's Employer:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Emergency Contact Information
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
Phone:
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?
Any parent or siblings had orthodontic treatment?
No
Yes
Does the Patient need to premedicate prior to dental visit?
No
Yes
If yes, please explain:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Abnormal swallowing (tongue thrust)?
No
Yes
Bleeding gums?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Frequently chew gum?
No
Yes
Frequent headaches?
No
Yes
Have wisdom teeth been removed?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Other periodontal (gum) problems?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Previous root canal therapy?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
Is all dental work completed at this time?
No
Yes
Please use this space for any additinoal information:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past.
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Does your bite feel uncomfortable or unusual?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Codeine or other narcotics?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Metal?
No
Yes
Penicillin or other antibiotics?
No
Yes
Sulfa drugs?
No
Yes
Other?
No
Yes
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.
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Any current or previous Bisphosphonate Treatment?
No
Yes
Any blood disorders?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Diabetes?
No
Yes
Growth problems?
No
Yes
Heart defect/disease or any Heart Problems?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV/AIDS/Immune system disorders?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Nervous disorders?
No
Yes
Persistent cough?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Prosthetic joints?
No
Yes
Respiratory problems or emphysema?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Smoking/Use of tobacco products?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Thyroid or endocrine problems?
No
Yes
Tonsils enlarged?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
FEMALES: Are you pregnant?
No
Yes
FEMALES: Are you trying to be pregnant?
No
Yes
Any additional information:
Any other conditions not listed above?
Patient Motivation For Orthodontic Treatment
What is the patient's main orthodontic concern?
How would you change your teeth?
How would you change your facial appearance?
Where would you like to reduce the pain or discomfort?
Patient's attitude towards treatment:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
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
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I authorize release of any information regarding my orthodontic treatment to my dental insurance company.
I give permission for dental radiographs to be taken when necessary for orthodontic treatment.
Signature:
Date:
Relationship to Patient (if patient is a minor):
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other