Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Home Phone:
Email:

If patient is a minor, give parent's or guardian's name(s)
Have other family members been patients here? If so, who?
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?

Responsible Party/Legal Guardian Information

First Name:
Middle Initial:
Last Name:
Marital Status:
Relationship to Patient:
Birthdate:
Address:
City:
State:
Zip:
Previous address (if above less than 2 years)?
Email:
Home Phone:
Mobile Phone:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Work Phone:
Driver's license #:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Birthdate:
Social Security Number:
Employer:
Occupation:
Length of Employment:
Mobile Phone:
Work Phone:

If patient is a minor and parents are divorced or separated, with whom does the child live?
Name of non-custodial parent:
Phone:
Address of non-custodial parent

Dental Insurance Information

Insurance Company Name:
Policy Holder's Name:
Insurance Company Phone:
Subscriber ID:
Group Number:
Birthdate:

Medical History

Physician Name:
Phone:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Please list any medications currently being taken by the patient (include non-prescription):
Please list any drug allergies:
Metal allergies?
Latex alergies?
Any medication/antibiotic needed prior to dental procedure?
Have you ever taken Fosamax or bisphosphonates class of bone medicine?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Adenoids removed?
AIDS/HIV?
Allergies/Sinus problems?
Anemia?
Arthritis?
Artificial heart valves?
Artificial joints?
Asthma?
Autistic disorder?
Blood/bleeding disorders?
Bone disorders?
Cancer?
Cardiac pacemaker?
Congenital heart lesions?
Chronic cough?
Diabetes?
Drug addiction?
Ear problems?
Eating disorders?
Emotional problems?
Endocrine disorders?
Epilepsy?
Faintness/dizziness?
Fever blisters?
Headaches (frequent)?
Heart murmur?
Heart trouble/condition?
Hepatitis?
Herpes?
High/low blood pressure?
Jaundice?
Joint swelling?
Kidney disease?
Organ Transplant?
Psychiatric treatment?
Radiation/chemo therapy?
Respiratory disease?
Rheumatic/scarlet fever?
Scoliosis?
Shortness of breath?
Seizures?
Speech problems?
Stroke?
Swelling of ankles?
Thyroid problems?
TMJ problems?
Tonsils removed?
Tuberculosis?
Venereal disease?
Whiplash?
FEMALES: Are You Pregnant?

Dental History

Dentist Name:
Date of last cleaning:
List any outstanding dental procedure that needs to be completed prior to orthodontic treatment:

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Bad bite?
Bruxing/grinding teeth?
Cheek/lip chewing?
Clenching teeth?
Fingernail biting?
Injury to face/teeth?
Periodontal (gum) disease?
Missing/extra teeth?
Mouth breathing?
Morning jaw joint paint?
Pain/clicking in jaw joint?
Tongue thrust?
Previous orthodontic treatment?
Previous tooth extraction?
Smoking history?
Thumb/finger/lip sucking?
TMJ treatment?
Please list any other medical or dental condition/illness not listed above:

Patients Under 18

If patient is under the age of 18, please answer the following questions:
School & District:
Names and ages of siblings:
Has patient begun puberty?