Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security Number:
How do you prefer to receive appointment reminders?

If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
What are the names of any friends or family currently in the practice?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Email:
Main Phone:
Cell Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Address:
City:
State:
Zip:
Insurance Company Phone:

Do you have dual dental coverage?
(If yes, complete information below)

Emergency Contact Information

Name
Relationship to Patient:
Main Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the patient have apprehension about dental care?
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.
Abnormal swallowing (tongue thrust)?
Bad taste or mouth odor?
Chipped or injured permanent teeth?
Wear a nightguard?
Discomfort from teeth or gums?
Floss teeth daily?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Numerous fillings?
Oral habits (thumb or finger sucking, lip or nail biting)?
Previous periodontal (gum) treatment?
Bleeding gums?
Previous root canal therapy?
Problems with food trapped between teeth?
Snores during sleep?
Family history of sleep apnea?
Speech problems or therapy?
Teeth sensitive to hot or cold?
Teeth that irritate tongue, cheek, lip, etc?
Is all dental work completed at this time?
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?
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:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
Codeine or other narcotics?
Latex?
Local anesthetics?
Penicillin or other antibiotics?
Metal allergy? If yes, please explain.
Other allergies or sensitivities? If yes, please explain.
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Bisphosphonates (Fosamax, Boniva)?
Chronic fatigue?
Diabetes?
Growth problems?
Handicaps or disabilities?
Substance abuse problem (past or present)?
Tonsils or adenoids removed?
FEMALES: Are You Pregnant?
If any of the above medical questions were answered 'Yes' , please explain:
Arteriosclerosis, Tuberculosis, lung disease, Pneumonia, cancer, cancer in family history, radiation treatment, thyroid or endocrine problems, stomach ulcer, hyperacidity, hormone therapy, nervous disorders? If yes, please explain.
Bone disorders, bone los, seizures, epilepsy, neurological disease, treated for emotional problems, asthma, respiratory problems, emphysema, persistent swollen neck glands, sexually transmitted disease, low blood pressure, or persistent cough? If yes, please explain.
Heart attack, stroke, congenital heart defect, heart disease, heart murmur, damaged or artificial heart valves? If yes, please explain.
Hemophilia, high blood pressure, hypertension, anemia, blood disorder, prolonged bleeding, transfusión, HIV or AIDS? If yes, plkease explain.
Kidney disease, liver disease, jaundice, or hepatitis? If yes, please explain.
Tonsils enlarged or sinus trouble? If yes, please explain.

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
Has the patient grown in the past year or has their shoe size changed recently?
Has either biological parent ever had orthodontic treatment?