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:
Mother/Guardian 2 Name:
Father/Guardian 1 Name:
Step Mother Name:
Step Father Name:
Please list the name and birthdate of any siblings:
School:
*
Home Phone:
Cell Phone: Mom
Cell Phone: Dad
Work Phone: Mom
Work Phone: Dad
Email: Mom
Email: Dad
Adopted:
No
Yes
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?
Growth Questionnaire
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
Family history of jaw growth problems/surgery?
No
Yes
If orthognathic (jaw) surgery is an option for your child, would you like this discussed with the child in the room or at a later follow up consultation?
Financial Party Information
*
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:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patients main orthodontic concern?
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Parent's interest in treatment:
Hoping for ideal aesthetics and function
Treatment of select issues
Treatment only if absolutely necessary
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
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
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 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
*
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
*
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:
Questionnaire for OSA Screening for Children
1. Does your child snore at night?
No
Yes
On a scale of 1-10, how loud is it?
1
2
3
4
5
6
7
8
9
10
2. Does your child wet the bed frequently?
No
Yes
3. Is it hard to wake your child in the morning?
No
Yes
4. Does your child breathe through their mouth during the day?
No
Yes
5. Does your child fall asleep during school?
No
Yes
6. Does your child have difficulty paying attention and focusing?
No
Yes
7. Has your child been diagnosed with ADHD?
No
Yes
8. Has your child had a sleep study?
No
Yes
9. Are you aware if your child has enlarged tonsils and adenoids?
No
Yes