Confidential Patient Biographical Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Email:
Social Security #:
Employer:
Occupation:
Marital Status:

If patient is a minor, who has legal custody of child?
Relationship:
If patient is a minor, who does the patient live with?
Relationship:
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.
Mother'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:
Spouse's Name:
Spouse's Phone:

Father'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:
Spouse's Name:
Spouse's Phone:

Emergency Information

Name of nearest relative not living with patient:
Relationship to Patient:
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?
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?
Any allergies or drug reactions? If so, please list.
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?
Autism Spectrum?
Bisphosphonates (Fosamax, Boniva)?
Blood (hemophilia, blood pressure)?
Cancer?
Chronic fatigue?
Developmental Delay?
Diabetes?
Heart (blood pressure, heart attack, murmur, heart disease)?
Joints (arthritis)?
Kidneys?
Lungs (asthma)?
Mobility (handicap)?
Pancreas?
Sexually transmitted disease?
FEMALES: Are You Pregnant?
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? If so, when?
Does the Patient need to premedicate prior to dental visit?

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)
Clench or grind teeth?
Frequently chew gum?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Oral habits (thumb or finger sucking, lip or nail biting)?
Previous medical dental work problem?
Speech problems or therapy?
Tongue Thrust?
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?
Do you have a history of jaw joint problems?
Have you been treated for TMJ?
Do you notice clicking or popping in your jaw joint?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Frequent Headaches?
Do you experience soreness in the muscles of your face or around your ears?
Neck or shoulder pain?
If any of the above TMJ questions were answered 'Yes', please explain:

Dental Insurance

Subscriber's Name:
Relationship to Patient:
Subscriber's Birthdate:
Subscriber's SS#:
ID NUmber:
Insurance Company Name:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Insurance Company Phone:
Signature:
By typing my name above I am electronically signing this form.