Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
Mother/Guardian 2 Name:
Father/Guardian 1 Name:
Step Mother:
Step Father Name:
Please list the name and birthdate of any siblings:
* Home Phone:
Cell Phone: Mom
Cell Phone: Dad
Work Phone: Mom
Work Phone: Dad
Email: Mom
Email: Dad
Adopted:
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:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Family history of jaw growth problems/surgery?
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:
Birthdate:
* 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 #:
Employer:
Occupation:
Work Phone #:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?
Patient's interest in treatment:
Parent's interest in treatment:
Has either biological parent ever had orthodontic treatment:
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
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
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
* 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
* HIV/AIDS
* 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
* Arthritis
* Ever Been Hospitalized
* Learning Disability
* Down Syndrome
* Other Genetic Condition/Syndrome
* ADHD
* 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:

Questionnaire for OSA Screening for Children

1. Does your child snore at night?
On a scale of 1-10, how loud is it?
2. Does your child wet the bed frequently?
3. Is it hard to wake your child in the morning?
4. Does your child breathe through their mouth during the day?
5. Does your child fall asleep during school?
6. Does your child have difficulty paying attention and focusing?
7. Has your child been diagnosed with ADHD?
8. Has your child had a sleep study?
9. Are you aware if your child has enlarged tonsils and adenoids?