Confidential Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Primary Phone:
2
nd
/Cell Phone:
Email:
For Adult Patients
Employer/Occupation:
Work Phone:
For Child Patients
School:
Grade:
Sports/Hobbies/Interests?
Whom may we thank for referring you to our practice?
Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Primary Phone:
Work Phone:
Cell/Other Phone:
Email:
Employer:
Occupation:
Social Security Number:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Separated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Primary Phone:
Work Phone:
Cell/Other Phone:
Email:
Employer:
Occupation:
Social Security Number:
Patient lives with:
Both Father & Mother
Father
Mother
Other
If other, please specify:
If divorced, who is the custodial parent?
Emergency Contact Information
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental Insurance Information
Do you have insurance that covers orthodontics?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company State:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Insurance Company Name:
Subscriber ID:
Group Number:
Policy Holder's Employer:
Insurance Company Phone:
Insurance Company State:
Dental History
Dentist Name:
Last Dental Visit:
Address:
Phone:
Yes
No
Are you currently seeing any other Dental Specialist(s)? If yes, who, and for what reason?
Yes
No
Is the patient presently in any dental pain?
Yes
No
Has the patient been advised by a physician that they require an antibiotic prior to dental treatment?
Yes
No
Have there been any injuries to face, mouth, or teeth? If yes, please explain:
Yes
No
Is there any sensitivity to temperature? Where?
Yes
No
Is there any sensitivity to pressure? Where?
Yes
No
Does the patient have any missing or extra permanent teeth?
Yes
No
Does the patient have any type of thumb or tongue habit?
Yes
No
Is the patient a mouth breather?
Yes
No
Does the patient snore?
Please check any of the following TMJ (jaw joint) symptoms that apply:
Grinding
Clenching
Jaw Joint Noises
Headaches or Neckaches
Jaw Joint Pain
Facial or Ear Pain
Locking or Difficulty Moving Jaws
Dental or Facial Trauma
Arthritis
TMJ Comments:
Orthodontic History
What is the patient's attitude toward receiving orthodontic treatment?
What is the patient's main orthodontic concern?
Would the patient change their facial appearance? If yes, in what way?
How would the patient change their facial appearance?
*
Yes
No
Has the patient ever seen an orthodontist? If yes, who and when?
*
Yes
No
Has anyone in the family received orthodontic treatment in this office?
*
Yes
No
Are you aware that some appointments will be during school/work hours?
Medical History
Physician Name:
Phone:
Date of Last Physical:
Address:
City:
State:
Zip:
*
Yes
No
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
*
Yes
No
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
Allergies or drug reaction to:
Aspirin, Ibuprofen, or Tylenol?
No
Yes
Latex?
No
Yes
Local anesthetics?
No
Yes
Metal?
No
Yes
Penicillin or other antibiotics?
No
Yes
Acrylics?
No
Yes
Please list any other drug allergies or sensitivities that the patient may have:
Please list any medications currently being taken by the patient (include non-prescription):
*
Yes
No
Does the patient have a chronic illness?
Yes
No
Does the patient have any handicaps/disabilities?
Yes
No
Is the patient adopted?
Yes
No
Female Patients only:
Is the patient pregnant?
Your answers are for office records only. A thorough medical history is essential to a complete orthodontic evaluation.
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Cerebral Palsy
Yes
No
Endocarditis
Yes
No
Anemia
Yes
No
Convulsions/Seizures
Yes
No
Herpes (oral cold sores)
Yes
No
Hypertension
Yes
No
Heart Disorder/Murmur
Yes
No
Stroke
Yes
No
Bone Problem or Disorder
Yes
No
Congenital Heart Disease
Yes
No
Fainting Spells
Yes
No
Arthritis/Joint Swelling
Yes
No
Rheumatic fever
Yes
No
Tuberculosis
Yes
No
Artificial Joint
Yes
No
Endocrine/Hormone Disorders
Yes
No
Prolonged Bleeding/Clotting Disorder
Yes
No
AIDS or HIV
Yes
No
Diabetes
Yes
No
Asthma
Yes
No
ADD/ADHD
Yes
No
Hepatitis or Liver Disorder
Yes
No
Emotional Disorders
Yes
No
Lung Disorder
Yes
No
Kidney or Bladder Disorder
Yes
No
Bronchitis
Yes
No
Breathing Difficulties
Yes
No
Speech Difficulties
Yes
No
Hearing Difficulties
Yes
No
Eating Disorders
Yes
No
Neurological Disorder
Yes
No
Birth Defects or Hereditary Problems
Yes
No
*
Yes
No
Does the patient have any learning disabilities or need extra help with instructions?
*
Yes
No
Has the patient ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate) for bone disorders or cancer?
*
Yes
No
Has the patient ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etldronate) for bone disorders?
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?
Patients Under 18
Brother/Sister Name:
Birthdate:
Yes
No
Had ortho treatment? If yes, where?
Brother/Sister Name:
Birthdate:
Yes
No
Had ortho treatment? If yes, where?
Brother/Sister Name:
Birthdate:
Yes
No
Had ortho treatment? If yes, where?
Brother/Sister Name:
Birthdate:
Yes
No
Had ortho treatment? If yes, where?
Brother/Sister Name:
Birthdate:
Yes
No
Had ortho treatment? If yes, where?
I certify that the preceding information is true and correct.
If there are any future changes in this information, I will inform the practice of these changes.
I realize that any diagnostic records taken in this office are the property of this office. We will be happy to furnish, upon request, a copy of these records to another orthodontist for a fee.