Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
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?
Dentist
Friend/Family
Insurance
Google
Yelp
Walk/Drive-by
Facebook
Instagram
Invisalign website
Other (please tell us how you heard about our office)
If 'Other' was selected, please tell us how you heard about our office.
Financial 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:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
Work Phone:
Emergency
Emergency Contact Name:
Relationship to patient:
Phone Number:
Dental History
Dentist Name (Please write N/A if you don't have one):
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
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.
Apprehensive about dental care?
No
Yes
Brush teeth daily?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Frequently chew gum?
No
Yes
Frequent headaches?
No
Yes
Frequent sore throats?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Have you ever had Botox or filler?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Neck or shoulder pain?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Requires premedication?
No
Yes
Snores during sleep?
No
Yes
Speech problems or therapy?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities 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.
ADHD?
No
Yes
Anemia or blood disorder?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Autism spectrum disorder?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Cold sores?
No
Yes
Diabetes?
No
Yes
Emotional problems treatment?
No
Yes
Endocrine problems?
No
Yes
Growth problems?
No
Yes
Handicaps or disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Heart defect (congenital)?
No
Yes
Heart disease?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
Hepatitis?
No
Yes
High blood pressure or hypertension?
No
Yes
HIV or AIDS?
No
Yes
Hormone therapy?
No
Yes
Ever been hospitalized?
No
Yes
Kidney disease?
No
Yes
Latex or Metal Allergy?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Nervous disorders?
No
Yes
Pneumonia?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Radiation treatment?
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Please list any other disorders or conditions not listed above:
Which of these treatments are you interested in (Please check all that apply)?
Angular cheilitis treatment
Asymmetric smile treatment
Jaw / profile balancing
Therapeutic botox and/or filler
Gum recontouring
Gummy smile treatment
Headache / orofacial pain treatment
Smile makeover
teeth grinding or clenching treatment
Teeth recontouring reshaping
Teeth straightening invisalign
Teeth straightening braces
Teeth whitening
TMJ disorder treatment
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Growth Status
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Sleep Questionnaire
While sleeping, does your child...
snore more than half the time?
Yes
No
always snore?
Yes
No
snore loudly?
Yes
No
have "heavy" or loud breathing?
Yes
No
have trouble breathing, or struggle to breathe?
Yes
No
Have you ever...
seen your child stop breathing during sleep?
Yes
No
Does your child...
tend to breathe through their mouth during the day?
Yes
No
have a dry mouth when waking up in the morning?
Yes
No
occasionally wet the bed?
Yes
No
wake up feeling unrefreshed in the morning?
Yes
No
have a problem with sleepiness during the day?
Yes
No
Has a teacher or supervisor commented that your child appears sleepy or sluggish during the day?
Yes
No
Is it hard to wake your child up in the morning?
Yes
No
Does your child wake up with headaches in the morning?
Yes
No
Did your child ever stop growing at a normal rate at any time since birth?
Yes
No
Is your child overweight?
Yes
No
This child often...
does not seem to not listen when spoken to directly?
Yes
No
has difficulty organizing tasks and activities?
Yes
No
is easily distracted by extraneous stimuli?
Yes
No
fidgets with hands or feet or squirms in seat?
Yes
No
is ‘on the go’ or often acts as if ‘driven by a motor’?
Yes
No
interrupts or intrudes on others?
Yes
No