Confidential Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Email:
Social Security #:
Employer:
Occupation:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Who is financially responsible for the account?
Whom may we thank for referring you to our practice?
Minor Biographical Information
If patient is an adult, please skip this section.
Who has legal custody of the child?
Relationship:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Stepfather
Stepmother
Other
Who does the patient live with?
Relationship:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Stepfather
Stepmother
Other
Please list any siblings and their ages:
Mother/Parent 1's Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Employer:
Occupation:
Length of Employment:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Spouse's Name:
Spouse's Phone:
Father/Parent 2's Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Employer:
Occupation:
Length of Employment:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Spouse's Name:
Spouse's Phone:
Emergency Information
Name of nearest relative not living with patient:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Address:
Phone:
Medical History
Physician Name:
Approximate date last seen:
Physician's Phone Number:
City:
State:
Is the patient now under the care of a physician/specialist (other than routine)? If so, what is being treated?
Yes
No
List any medications currently being taken by the patient (include non-prescription):
Has the patient had a serious illness/hospitalization/surgeries in the past? If so, what for?
Yes
No
Any allergies or drug reactions? If so, please list.
Yes
No
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anxiety/Depression?
Yes
No
Autism Spectrum?
Yes
No
Bisphosphonates (Fosamax, Boniva)?
Yes
No
Blood (hemophilia, blood pressure)?
Yes
No
Cancer?
Yes
No
Chronic fatigue?
Yes
No
Developmental Delay?
Yes
No
Diabetes?
Yes
No
Hearing?
Yes
No
Heart (blood pressure, heart attack, murmur, heart disease)?
Yes
No
Joints (arthritis)?
Yes
No
Kidneys?
Yes
No
Lungs (asthma)?
Yes
No
Mobility (handicap)?
Yes
No
Pancreas?
Yes
No
Sexually transmitted disease?
Yes
No
Vision?
Yes
No
FEMALES: Are You Pregnant?
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
Dental History
Dentist Name:
Approximate date last seen:
What is the patient's main orthodontic concerns and goals for treatment?
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
Does the Patient need to premedicate prior to dental visit?
Yes
No
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Breathing/Respiration (tonsils/adenoids removed, sleep apnea, CPAP, trouble breathing through nose/snoring)
Yes
No
Clench or grind teeth?
Yes
No
Frequently chew gum?
Yes
No
Injury to face, jaw, teeth, or mouth?
Yes
No
Missing or extra permanent teeth?
Yes
No
Oral habits (thumb or finger sucking, lip or nail biting)?
Yes
No
Previous medical dental work problem?
Yes
No
Speech problems or therapy?
Yes
No
Tongue Thrust?
Yes
No
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.
Have you had a TMJ screening?
Yes
No
Do you have a history of jaw joint problems?
Yes
No
Have you been treated for TMJ?
Yes
No
Do you notice clicking or popping in your jaw joint?
Yes
No
Has your jaw ever locked?
Yes
No
Do you have difficulty chewing or opening your mouth?
Yes
No
Does your bite feel uncomfortable or unusual?
Yes
No
Frequent Headaches?
Yes
No
Do you experience soreness in the muscles of your face or around your ears?
Yes
No
Neck or shoulder pain?
Yes
No
If any of the above TMJ questions were answered 'Yes', please explain:
Dental Insurance
Subscriber's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Subscriber's Birthdate:
Subscriber's SS#:
ID NUmber:
Insurance Company Name:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Company Phone:
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.
Our office utilizes the use of CBCT technology (3-D imaging) as an orthodontic tool to assess bone width, impacted and ectopic teeth, root position and gross anatomical anomalies, general pathology screening, more accurate location of vital structures for extractions, and orthognathic planning and evaluation. This imaging is used for orthodontic purposes only and will be reviewed by Emily S. Willett D.D.S., M.S. If you would like the image interpreted beyond orthodontic purposes, we can send it to a dental radiologist lab for an additional cost. I understand that my CBCT (3-D image) will be examined for orthodontic purposes only.
Signature:
By typing my name above I am electronically signing this form.