Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname/Preferred Name:
Birthdate:
Gender:
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

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Birthdate:
Relationship to Patient:
Occupation:
Work Phone:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Occupation:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
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?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
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:
Address:
Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Any parent or siblings had orthodontic treatment?
Does the Patient need to premedicate prior to dental visit?
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)?
Bleeding gums?
Chipped or injured permanent teeth?
Clench or grind teeth?
Discomfort from teeth or gums?
Frequent canker sores or cold sores?
Frequently chew gum?
Frequent headaches?
Have wisdom teeth been removed?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Other periodontal (gum) problems?
Previous periodontal (gum) treatment?
Previous root canal therapy?
Snores during sleep?
Speech problems or therapy?
Is all dental work completed at this time?
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?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Do you experience soreness in the muscles of your face or around your ears?
If any of the above TMJ questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Sulfa drugs?
Other?
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?
Asthma?
Any current or previous Bisphosphonate Treatment?
Any blood disorders?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Growth problems?
Heart defect/disease or any Heart Problems?
High blood pressure or hypertension?
HIV/AIDS/Immune system disorders?
Hormone therapy?
Kidney disease?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Persistent cough?
Prolonged bleeding or transfusion?
Prosthetic joints?
Respiratory problems or emphysema?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Smoking/Use of tobacco products?
Substance abuse problem (past or present)?
Thyroid or endocrine problems?
Tonsils enlarged?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
FEMALES: Are you pregnant?
FEMALES: Are you trying to be pregnant?
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?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Signature:
Date:
Relationship to Patient (if patient is a minor):