Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
If patient is a minor, who is accompanying them today?
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
If patient is a minor, who does the patient live with?
Family members seen in our practice:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?
How did you hear about our office?
Website
Internet Search
General Dentist
Facebook
Insurance Company
Parent was a patient
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Partner/Spouse if different from below:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Other Party's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Partner/Spouse if different from above:
Address:
City:
State:
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:
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
Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Policy Holder's Employer:
Emergency Contact Information
Name:
Address:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the patient need to be Premedicated with antibiotics for Dental Procedures?
No
Yes
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.
Abnormal swallowing (tongue thrust)?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Floss teeth daily?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Frequent headaches?
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
Previous periodontal (gum) treatment?
No
Yes
Snoring or sleep apnea?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
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 all of the drugs you are currently taking, including over the counter & recreational:
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Codeine or other narcotics?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Nickel?
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.
Anemia or blood disorder?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Attention or sensory problems?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Cancer/Chemotherapy?
No
Yes
Diabetes?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Heart valves are damaged or artificial?
No
Yes
Hemophilia or abnormal bleeding?
No
Yes
Blood pressure problems?
No
Yes
HIV or AIDS?
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
Pneumonia?
No
Yes
Prosthetic joints?
No
Yes
Radiation treatment to head & neck?
No
Yes
Respiratory problems or emphysema
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Sexually transmitted disease?
No
Yes
Sinus trouble?
No
Yes
Stomach ulcer or colitis?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
FEMALES: Are You Pregnant?
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:
School:
Grade:
Has patient begun puberty?
No
Yes
Has either biological parent ever had orthodontic treatment?
Don't know
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.