Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Social Security #:
Email:
Cell Phone:
Address:
City:
State:
Zip:

If patient is a minor, give parent's or guardian's name:
Patient's Dentist:
Who suggested that you might need orthodontic treatment?
Main reason for seeking orthodontic treatment?
Whom may we thank for referring you to our office?

Dental Insurance Information

Insurance Company:
Group Number:
Subscriber ID:
Subscriber's Birthdate:
Phone Number:
Do you have dual dental coverage?
(If yes, complete information below)
Insured's Name:
Insured's Social Security #:

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Social Security Number:
Birthdate:
Relationship to Patient:
Cell Phone:
Employer:
Occupation:

Spouse's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:

Emergency Contact Information

Name:
Relationship to Patient:
Phone:

Medical History

Physician:
Phone:

Please select Yes or No. Parents/Guardians please respond for minors. Cannot be blank.
*
Are you taking any medication/supplements/herbals?
*
Are you allergic to any medication/foods/latex/metals/acrylics/anesthetics etc?
*
Do you have a history of a major illness?
*
Have you had any major operations?
*
Have you ever been involved in a serious accident?
*
Are you/have you taking/taken bisphosphonates for osteoporosis or other bone diseases?
*
Do you chew or smoke tobacco products? If so, how long?
*
Do you have or have you ever had a substance abuse problem?
*
Does your physician recommend premedicating with antibiotics prior to dental procedures?
Abnormal bleeding/Hemophilia?
Anemia or blood disorder?
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 / AIDS?
Kidney Problems?
Nervous Disorders?
Pneumonia?
Prolonged Bleeding?
Radiation / Chemotherapy?
Rheumatic fever?
Sleep Apnea?
Tuberculosis?
Tumor or Cancer?
Female Patients only:
Are you pregnant?
Has menstruation started (this is useful in monitoring/modifying growth of head and jaw bones)?
If any of the above medical questions were answered 'Yes' , please explain:
Are there any medical conditions we have not discussed that you feel we should be aware of?

Dental History

Last Dental Visit:
*
Have you ever seen an orthodontist? If yes, who and when?
*
Have you been seeing your general dentist for routine check-ups every 6 months?
*
Are you presently in any dental pain?
*
Have you ever experienced any unfavorable reaction to dentistry?
*
Have you ever lost or chipped any teeth?
*
Have there been any injuries to face, mouth or teeth?
*
Is any part of your mouth sensitive to temperature or pressure?
*
Do your gums bleed when you brush?
*
Do you have any type of thumb or tongue habit?
*
Are you a mouth breather?
*
Do you snore loudly?
*
Do you often feel tired, fatigued, or sleepy throughout the day?
*
Are you being treated for sleep apnea?
*
Do you have/have you had a tonsil or adenoid condition?
*
Have you been told you have a tongue thrust?
*
What is your attitude toward receiving orthodontic treatment?
*
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
*
Are you aware of your jaw clicking or popping?
*
Are you aware of clenching your teeth during the day?
*
Have you ever been told that you grind your teeth?
*
Do you have "tension" headaches?
*
Are there any familial medical conditions we should know about?
If any of the above dental questions were answered 'Yes', please explain:

Fun Facts for Kids (and Adults)

Nickname:
School and grade level:
Favorite hobby:
Favorite food:
Favorite animal:
Favorite person:
Favorite sport:
Favorite musical artist:
Musical instrument(s) played:
Siblings?
Any other information you would like us to know: