Patient Information

First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Nickname:
Birthdate:
Gender:
Parent or guardian name:
Whom may we thank for referring you to our practice?

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Residence:
City:
State:
Zip:
Mailing address:
City:
State:
Zip:
How long at this address?
Previous address (less than 3 years)?
Social Security Number:
Birthdate:
Relationship to Patient:
Home Phone:
Work Phone:
Cell/Other Phone:
Email:
Employer:
Occupation:
No. years employed:
Spouse's First Name:
Middle Initial:
Last Name:
Social Security Number:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Phone:

Dental Insurance Information

Insured's Name:
Insured's Social Security Number:
Insurance Company Name:
Group Name:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:
Do you have dual dental coverage?
(If yes, complete information below)
Insured's Name:
Insured's Social Security Number:
Insurance Company Name:
Group Name:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Emergency Contact Information

Name of nearest relative not living with you:
Phone:
Address:
City:
State:
Zip:

Medical History

Physician:
Date of Last Visit:
Phone:
Address:
City:
State:
Zip:
Please select Yes or No (If Yes, please fill in details) regarding patient's medical history
*
Taking any medication?
*
Allergic to any medication?
*
Any other allergies?
*
Any history of major illness?
*
Any major operations?
*
Ever been involved in a serious accident?
*
Ever taken any medication for bone loss (such as Fosamax or Boniva)?
*
Need to premedicate for any dental or medical procedures?
*
Physical or mental disabilities?
Ethnicity (used for Diagnostic Purposes only):
Women: Are you pregnant or planning on becoming pregnant?
Please select 'Yes' for any of the medical conditions below that the patient has had or currently has. Cannot be blank.
Abnormal bleeding/Hemophilia?
Anemia?
Arthritis?
Asthma or Hayfever?
Bone disorders?
Congenital heart defect?
Diabetes?
Dizziness?
Epilepsy?
Gastrointestinal Disorders?
Heart problems?
Heart murmur?
Hepatitis/Liver problems?
Herpes?
High blood pressure?
HIV or AIDS?
Kidney problems?
Nervous disorders?
Pneumonia?
Prolonged bleeding?
Radiation/Chemotherapy?
Rheumatic fever?
Tuberculosis?
Tumor or cancer?
Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

General Dentist:
Date of Last Visit:
Main concern for evaluation?
Patient's attitude toward receiving orthodontic treatment?
Please select Yes or No (If Yes, please fill in details) regarding patient's dental/oral history
*
Ever experienced any unfavorable reaction to dentistry?
*
Have there been any injuries to face, mouth, or teeth?
*
Any type of thumb or tongue habit?
*
A mouth breather?
*
Speech therapy?
*
Has anyone in the family received orthodontic treatment? How did they feel about the result?
*
Do teeth or jaws ever feel uncomfortable first thing in the morning?
*
Experience jaw clicking or popping?
*
Aware of clenching or grinding teeth during the day?
*
Experience "tension" headaches?
*
Ever experienced chronic ringing in the ears?
*
Sensitive or self-concious about his/her teeth?
Are there any other issues or concerns we should be aware of?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
Biological mother's height:
Biological dad's height:
*
If patient is a girl: has menstruation started? If yes, when?