Confidential Patient Information
*First Name:
*
Middle Initial:
*Last Name:
*
Nickname:
*Birthdate:
*
*
*Gender:
Male
Female
*
*Address:
*
*City:
*
*State:
*
*Zip:
*
*Main Phone:
*
2nd/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
*
Middle Initial:
*Last Name:
*
*Birthdate:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
Address same as patient.
*Address:
*
*City:
*
*State:
*
*Zip:
*
*Main Phone:
*
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
*
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
*
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
*
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
No
Yes
*
Grind or clench teeth?
*
No
Yes
Injury to face, jaw, teeth or mouth?
*
No
Yes
Discomfort from teeth or gums?
*
No
Yes
Pain, tenderness or noise in either jaw?
*
No
Yes
Frequent headaches?
*
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
*
No
Yes
Neck/shoulder pain?
*
No
Yes
Frequent sore throats?
*
No
Yes
Brush teeth daily?
*
No
Yes
Floss teeth daily?
*
No
Yes
Fluoride treatments?
*
No
Yes
Mouth breathing?
*
No
Yes
Snores during sleep?
*
No
Yes
Requires premedication?
*
No
Yes
Any missing or extra permanent teeth?
*
No
Yes
Apprehensive about dental care?
*
No
Yes
Frequently Chew Gum?
*
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of last Physical:
*
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
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 - Do Not Leave Blank
Rheumatic Fever
*
No
Yes
Tuberculosis/Lung Disease
*
No
Yes
Pneumonia
*
No
Yes
Liver Disease
*
No
Yes
Kidney Disease
*
No
Yes
Heart Attack/Stroke
*
No
Yes
Heart Disease
*
No
Yes
Congenital Heart Defect
*
No
Yes
Heart Murmur
*
No
Yes
Hemophilia
*
No
Yes
Hypertension/High Blood Pressure
*
No
Yes
Prolonged Bleeding/Transfusion
*
No
Yes
Anemia
*
No
Yes
HIV/AIDS
*
No
Yes
Hepatitis
*
No
Yes
Tonsils/Adenoids Removed
*
No
Yes
Cancer
*
No
Yes
Family History of Cancer
*
No
Yes
Received Radiation Treatment
*
No
Yes
Growth Problems
*
No
Yes
Endocrine Problems
*
No
Yes
Hormone Therapy
*
No
Yes
Latex/Metal Allergy
*
No
Yes
Nervous Disorders
*
No
Yes
Bone Disorders/Bone Loss
*
No
Yes
Diabetes
*
No
Yes
Seizures/Epilepsy
*
No
Yes
Handicaps/Disabilities
*
No
Yes
Asthma
*
No
Yes
Arthritis
*
No
Yes
Treated for Emotional Problems
*
No
Yes
Ever Been Hospitalized
*
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No