Patient Biographical Information
*
First Name:
Middle Initial:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male/Man
Female/Woman
TransMale/TransMan
TransFemale/TransWoman
Genderqueer/Gender nonconforming
Something Else
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Home Phone:
Cell Phone:
Work Phone:
Email:
Please list any hobbies or special interests:
Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?
Financial Party Information
Please select if you are the patient and will also the person who will be financially responsible for treatment.
*
First Name:
Middle Initial:
*
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Birthdate:
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
Do you have dental insurance that covers orthodontics?
No
Yes
If you would like us to check your benefits prior to your examination, please fill in these fields:
Insurance Company:
Member/Subscriber ID:
Group #:
Employer:
Occupation:
Work Phone #:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Have you had a previous orthodontic consult or treatment?
No
Yes
If so, when?
What is your main orthodontic concern?
My interest in treatment is:
Hoping for ideal aesthetics and function
Treatment of select issues
Treatment only if absolutely necessary
Please select YES or No for the Following Questions - Do Not Leave Blank
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Pain, tenderness or noise in either jaw?
No
Yes
*
Grind or clench teeth?
No
Yes
*
Neck/shoulder pain?
No
Yes
*
Received TMJ Treatment
No
Yes
*
Speech problems/therapy?
No
Yes
*
Discomfort from teeth or gums?
No
Yes
*
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Frequent sore throats?
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
*
Treatment for periodontal disease
No
Yes
*
Dry Mouth
No
Yes
*
Family history of jaw growth problems/surgery
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:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
List any medications currently being taken:
List any drug allergies or sensitivities that you 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
*
Heart Murmur
No
Yes
*
Congenital Heart Defect
No
Yes
*
Requires antibiotics prior to procedures due to heart defect
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
*
Received Radiation Treatment
No
Yes
*
Growth Problems
No
Yes
*
Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Latex Allergy
No
Yes
*
Metal Allergy
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Diabetes
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Asthma
No
Yes
*
Sleep Apnea
No
Yes
*
Arthritis
No
Yes
*
Ever Been Hospitalized
No
Yes
*
Learning Disability
No
Yes
*
Down Syndrome
No
Yes
*
Other Genetic Condition/Syndrome
No
Yes
*
ADHD
No
Yes
*
Anxiety
No
Yes
*
Depression
No
Yes
*
Autism
No
Yes
Autism level: (only answer if applicable i.e. patient has autism)
N/A
Mild
Moderate
Severe
*
Other psychiatric problems
No
Yes
*
Eating Disorder
No
Yes
*
Sensory Processing Disorder
No
Yes
If any of the above medical questions were answered 'Yes', please explain:
Sleep Apnea Screening for Adults
1. Do you snore at night?
No
Yes
2. Do you wake several times throughout the night?
No
Yes
3. Is it difficult to wake in the morning?
No
Yes
4. Do you feel tired mid-day?
No
Yes
5. Do you grind your teeth at night?
No
Yes