TELL US ABOUT YOURSELF
Today's Date:
SSN:
First Name:
Middle Initial:
Last Name:
Nickname:
Gender:
Male
Female
Birthdate:
Age:
Home #:
Cell #:
Work #:
Ext:
Home Address:
City:
State:
Zip:
Email Address:
Marital Status:
Single
Married
Divorced
Separated
Widowed
Employer:
Employer Address:
Job Title:
Where and when are best times to reach you?
Whom may we thank for referring you?
Other family members seen by us:
General Dentist:
Date of Last Visit:
SPOUSE INFORMATION
His/Her Name:
Birthdate:
Employer:
Work #:
Ext:
Job Title:
SSN:
PERSON RESPONSIBLE FOR ACCOUNT:
You
Your Spouse
Billing Address:
City:
State:
Zip:
WHO TO CONTACT IN AN EMERGENCY
Name:
Relation:
Work #:
Ext:
Home #:
Personal Physician:
Phone #:
Date of Last Visit:
ORTHODONTIC
INSURANCE
Orthodontic coverage?
Yes
No
Primary Dental Insurance:
Policy Holder:
Address:
ID#:
GR#:
Secondary Dental Insurance:
Policy Holder:
Address:
ID#:
GR#:
Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
DENTAL HISTORY
What is your main concern with regard to your teeth?
Have you ever had or been evaluated for orthodontic treatment?
No
Yes
Have you ever had a serious or difficult problem associated with any previous dental work?
Yes
No
If yes, please explain:
Have you previously had your wisdom teeth extracted?
Yes
No
Do you now or have you ever experienced pain/clicking/locking of your jaw joint(s)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you like your smile?
Yes
No
Do your gums ever bleed?
Yes
No
Any speech problems?
Yes
No
Any missing or extra permanent teeth?
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
N/A
Do you breath through your mouth?
Yes
No
If so, when?
While awake
While asleep
Do you snore?
Yes
No
Chew gum often?
Yes
No
Smoke?
Yes
No
Chew tobacco?
Yes
No
MEDICAL HISTORY
HAVE YOU EVER EXPERIENCED ANY OF THE FOLLOWING MEDICAL PROBLEMS?
Bleeding / Clotting disorder?
No
Yes
Convulsions / Epilepsy
No
Yes
Handicaps / Disabilities
No
Yes
Mouth Sores
No
Yes
Any hostpital stays
No
Yes
Hearing Impairment
No
Yes
Any surgeries
No
Yes
ADD / ADHD
No
Yes
Artificial bones / joints / valves
No
Yes
Hepatitis
No
Yes
Asthma
No
Yes
HIV+ / AIDS
No
Yes
Cancer
No
Yes
Kidney / Liver problems
No
Yes
Congenital heart defect
No
Yes
Rheumatic / Scarlet fever
No
Yes
Heart murmur
No
Yes
Sickle Cell Disease
No
Yes
Diabetes
No
Yes
Tuberculosis
No
Yes
Drug reaction
No
Yes
Latex or Metal allergy
No
Yes
Other medical problem(s)
No
Yes
Please describe your current physical health:
Good
Fair
Poor
Please list all the drugs you are currently taking:
Please list all the drugs you are allergic to:
DO YOU NOW, OR HAVE YOU EVER EXHIBITED ANY OF THE FOLLOWING HABITS?
Lib sucking or biting
No
Yes
Nail biting
No
Yes
Teeth grinding/clenching
No
Yes
Thumb/finger sucking
No
Yes
Tongue thrusting
No
Yes
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my medical status.
Signature of patient:
Date:
I authorize the dental staff to perform the necessary orthodontic services I may need.
Signature of patient:
Date: