Confidential Patient Information

First Name:
MI:
Last Name:
Nickname:
Birthdate:
Gender:
Preferred Pronoun:
Address:
City:
State:
Zip:
Cell Phone:
2nd/Cell Phone:
Email:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
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?
Please rate the following with 5 being the most important and 1 being the least.
Comfort of treatment:
Length of treatment:
Clear or invisible treatment options:
Latest technology for treatment:
Low down payment:
Low monthly payments:
Starting treatment as soon as possible:

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Email:
Cell Phone:
2nd Phone:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Employer:
Occupation:
Cell Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's D.O.B:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Policy Holder's D.O.B:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
I assign my benefits to Family Orthodontics.
Signature:
Date:

Emergency Information

Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:

Dental History

Dentist Name:
Check-up Frequency:

If your teeth could be changed, how would you like them to change? (Spacing, crowding, flaring, etc.)

If your facial appearance could be changed, what would you change? (Jaw position, lip support, gum display, etc.)

Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
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.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Frequent headaches, neck, shoulder or ear pain?
Chipped or injured permanent teeth?
Abnormal swallowing (tongue thrust)?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Thumb or finger habit as a child?
Periodontal (gum) problems?
Problems with food trapped between teeth?
Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you have difficulty chewing or opening your mouth?
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:
Any airway concerns?
Snores during sleep?
Sleep apnea?
Mouth breathing?
Tonsils & adenoids removed?
Poor sleep quality?

Medical History

Physician Name:
Patient Overall Health:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Metal Allergy
Other:
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Angina
Heart Attack/Stroke
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Bed wetting
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Low blood pressure
Persistent cough
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
Systemic disease
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:
Height:
Weight:
School:
Grade:
Has adolescent growth spurt begun?
Is there any known family history of an underbite?
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment: