Confidential Biographical Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Primary Phone:
2nd/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

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
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:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Primary Phone:
Work Phone:
Cell/Other Phone:
Email:
Employer:
Occupation:
Social Security Number:

Patient lives with:
If other, please specify:
If divorced, who is the custodial parent?

Emergency Contact Information

Name:
Relationship to Patient:
Phone:

Dental Insurance Information

Do you have insurance that covers orthodontics?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Birthdate:
Policy Holder's Employer:
Subscriber ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insurance Company State:

Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
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:
Are you currently seeing any other Dental Specialist(s)? If yes, who, and for what reason?
Is the patient presently in any dental pain?
Has the patient been advised by a physician that they require an antibiotic prior to dental treatment?
Have there been any injuries to face, mouth, or teeth? If yes, please explain:
Is there any sensitivity to temperature? Where?
Is there any sensitivity to pressure? Where?
Does the patient have any missing or extra permanent teeth?
Does the patient have any type of thumb or tongue habit?
Is the patient a mouth breather?
Does the patient snore?
Please check any of the following TMJ (jaw joint) symptoms that apply:
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?
*
Has the patient ever seen an orthodontist? If yes, who and when?
*
Has anyone in the family received orthodontic treatment in this office?
*
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:

*
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
*
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?
Latex?
Local anesthetics?
Metal?
Penicillin or other antibiotics?
Acrylics?
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):
*
Does the patient have a chronic illness?
Does the patient have any handicaps/disabilities?
Is the patient adopted?
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
Endocarditis
Anemia
Convulsions/Seizures
Herpes (oral cold sores)
Hypertension
Heart Disorder/Murmur
Stroke
Bone Problem or Disorder
Congenital Heart Disease
Fainting Spells
Arthritis/Joint Swelling
Rheumatic fever
Tuberculosis
Artificial Joint
Endocrine/Hormone Disorders
Prolonged Bleeding/Clotting Disorder
AIDS or HIV
Diabetes
Asthma
ADD/ADHD
Hepatitis or Liver Disorder
Emotional Disorders
Lung Disorder
Kidney or Bladder Disorder
Bronchitis
Breathing Difficulties
Speech Difficulties
Hearing Difficulties
Eating Disorders
Neurological Disorder
Birth Defects or Hereditary Problems

*
Does the patient have any learning disabilities or need extra help with instructions?
*
Has the patient ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate), or Didronel (etidronate) for bone disorders or cancer?
*
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:
Had ortho treatment? If yes, where?

Brother/Sister Name:
Birthdate:
Had ortho treatment? If yes, where?

Brother/Sister Name:
Birthdate:
Had ortho treatment? If yes, where?

Brother/Sister Name:
Birthdate:
Had ortho treatment? If yes, where?

Brother/Sister Name:
Birthdate:
Had ortho treatment? If yes, where?