Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Marital Status:
Spouse's Name:
* Address:
* City:
* State:
* Zip:
Do you have children?
If Yes, Names and Ages:
Person Financially Responsible:
Home Phone:
Cell:
Work Phone #:
Which is the best phone number for contact?
Email (Used for Appointment Reminders):
Hobbies:
Who can we thank for referring you?

Insurance Information

Dental Insurance Company:
Policy Number:
Policy Holder's Name:
SSN:
Birthdate:
Policy Holder's Employer:
Work Phone:

Secondary Dental Insurance:
Policy Number:
Policy Holder's Name:
SSN:
Birthdate:
Policy Holder's Employer:
Work Phone:

Dental History

Dentist Name:
Date of Last Exam:
Does the patient currently have any untreated/unfinished dental needs?
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?

Please select YES or No for the Following Questions and Explain as Necessary
* Speech problems/therapy?
* Grind or clench teeth?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Injury to face, jaw, teeth or mouth?
* Pain, tenderness or noise in jaw?
* Unbalanced Jaw Size/Growth
* Apprehensive about dental care?
* Brush Teeth Twice Daily?
* Floss teeth daily?
* Mouth breathing?
* Snores during sleep?
* Requires premedication?
* Any Missing or Extra Permanent Teeth?
* Family History With Orthodontics
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Exam:
Address:
City:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the following questions and explain as necessary.
* Rheumatic Fever
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Congenital Heart Defect
* Heart Murmur
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* If Female, Pregnant or Nursing
* Latex/Metal Allergy
* Nervous Disorders
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Arthritis
* Treated for Emotional Problems
* Osteoporosis or Low Bone Density
* Autism
* ADHD/ADD
Please explain any 'Yes' responses from above:
* Responsible Party Name:
* Date: