All fields marked with an
*
are required fields and must be filled out.
Patient Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
Other
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Mother/Guardian's Name:
Father/Guardian's Name:
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?
Patient Motivation for Orthodontic Treatment
Please help us to understand your concerns or desires by sharing the following information; please be specific
General Concerns:
Teeth/Smile - Is there anything about your smile or teeth that you'd like to change?
Symptoms:
Dental History
Dentist Name:
Check-up Frequency:
Select
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Have your teeth changed in the last five years, become shorter, thinner, or worn? If yes, please explain:
No
Yes
Do you wear/have you ever worn a bite appliance?
No
Yes
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech concerns/therapy?
No
Yes
Snores during sleep?
No
Yes
Grind or clench teeth?
No
Yes
Diagnosis of Sleep Apnea
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Wake up tired after a full night of sleep
No
Yes
Neck/shoulder pain?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Discomfort from teeth or gums?
No
Yes
Requires premedication for dental visits?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Any missing or extra teeth?
No
Yes
Dry mouth (Sjogene's syndrome?
No
Yes
Frequent headaches?
No
Yes
Sensitive gagging reflex?
No
Yes
Mouth breathing?
No
Yes
If any of the above dental questions were answered 'Yes' or you have any other dental concerns, please explain:
Medical History
Physician Name:
Date of last Physical:
Patient Health:
Select
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
No
Yes
Growth Problems
No
Yes
Tuberculosis/Lung Disease
No
Yes
Endocrine/Thyroid Problems
No
Yes
Pneumonia
No
Yes
Hormone Therapy
No
Yes
History of smoking
No
Yes
Tonsils/Adenoids Removed
No
Yes
Liver Disease
No
Yes
Diabetes
No
Yes
Kidney Disease
No
Yes
Bone Disorders/Bone Loss
No
Yes
Heart Disease
No
Yes
Seizures/Epilepsy
No
Yes
Heart Attack/Stroke
No
Yes
Faints easily
No
Yes
Heart Murmur
No
Yes
Inflamatory Rheumatism
No
Yes
Congenital Heart Defect
No
Yes
Arthritis
No
Yes
Hypertension/High Blood Pressure
No
Yes
Handicaps/Disabilities
No
Yes
Hemophilia
No
Yes
Asthma
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
ADHD
No
Yes
Anemia
No
Yes
Anxiety with new experiences
No
Yes
Hepatitis
No
Yes
Autism
No
Yes
HIV/AIDS
No
Yes
Latex Allergy
No
Yes
Metal Allergy
No
Yes
Cancer
No
Yes
Herpes (Oral cold sores)
No
Yes
Received Radiation Treatment
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
If other relationship, please explain:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone #:
By typing my name below, 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.