Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone:
Work Phone:
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

* First Name:
Middle Initial:
* Last Name:
Relationship to Patient:
* Address:
* City:
* State:
* Zip:
Do you have dental insurance that covers orthodontics?
If you would like us to check your benefits prior to your examination, please fill in these fields:
Insurance Company:
Member/Subscriber ID:
Group #:
Work Phone #:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Have you had a previous orthodontic consult or treatment?
If so, when?
What is your main orthodontic concern?
My interest in treatment is:
Please select YES or No for the Following Questions - Do Not Leave Blank
* Injury to face, jaw, teeth or mouth?
* Pain, tenderness or noise in either jaw?
* Grind or clench teeth?
* Neck/shoulder pain?
* Received TMJ Treatment
* Speech problems/therapy?
* Discomfort from teeth or gums?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Frequent sore throats?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
* Treatment for periodontal disease
* Dry Mouth
* Family history of jaw growth problems/surgery
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
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
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Heart Murmur
* Congenital Heart Defect
* Requires antibiotics prior to procedures due to heart defect
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex Allergy
* Metal Allergy
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Sleep Apnea
* Arthritis
* Ever Been Hospitalized
* Learning Disability
* Down Syndrome
* Other Genetic Condition/Syndrome
* Anxiety
* Depression
* Autism
Autism level: (only answer if applicable i.e. patient has autism)
* Other psychiatric problems
* Eating Disorder
* Sensory Processing Disorder
If any of the above medical questions were answered 'Yes', please explain:

Sleep Apnea Screening for Adults

1. Do you snore at night?
2. Do you wake several times throughout the night?
3. Is it difficult to wake in the morning?
4. Do you feel tired mid-day?
5. Do you grind your teeth at night?