Patient Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
School:
Grade:
Mother's Name:
Father's Name:
* Address:
* City:
* State:
* Zip:
Child Lives With:
Person Financially Responsible:
Home Phone:
Mom Cell:
Dad Cell:
Which is the best phone number for contact?
Email Address (Used for Appointment Reminders):
Who can we thank for referring you?
Names and Birthdates of Siblings:

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?
Has your dentist taken a panoramic x-ray in the past year?
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:

Patients Under 18

Has patient begun puberty:
If female, has menstruation begun:
If so, when?
If male, has voice changed or facial hair appeared:
Has the patient grown significantly in the last year?
Patient's interest in orthodontic treatment:
* Responsible Party Name:
* Date: