Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
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?
Please select YES or No for the Following Questions - Do Not Leave Blank. If the answer is SOMETIMES or MAYBE, please mark YES and clarify in the box below.
Speech problems/therapy?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Mouth breathing?
No
Yes
Requires premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
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:
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. If the answer is SOMETIMES or MAYBE, please mark YES and clarify in the box below.
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
Congenital Heart Defect
No
Yes
Heart Murmur
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
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Growth Problems
No
Yes
Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Latex/Metal Allergy
No
Yes
Nervous Disorders
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
Treated for Emotional Problems
No
Yes
Ever Been Hospitalized
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Airway Questionnaire
Daytime Symptoms
Are you frequently sick (Ex: colds, flu)
No
Yes
Fatigue
No
Yes
Myalgia-Muscle aches, pains, soreness
No
Yes
Difficulty concentrating
No
Yes
Need caffeine throughout the day
No
Yes
Frequent neck soreness
No
Yes
Forgetfulness
No
Yes
Sleep Disturbances
Regular use of sleep aids
No
Yes
Difficulty initiating sleep
No
Yes
Insomnia (difficulty maintaining sleep)
No
Yes
Nighttime bathroom trips
No
Yes
Bruxism, Teeth Grinding, Clenching
No
Yes
Restless leg syndrome
No
Yes
Unrefreshed sleep
No
Yes
GERDS/acid reflux
No
Yes
Snoring
No
Yes
Dry mouth at night or upon wakening
No
Yes
Chapped lips
No
Yes
Functional Somatic Syndrome
Depression
No
Yes
Chronic Fatigue Syndrome
No
Yes
Irritable Bowel Syndrome
No
Yes
Fibromyalgia
No
Yes
Polysomatic Disorder
No
Yes
Mood Swings/Irritability
No
Yes
Anxiety/Panic Attacks
No
Yes
Autonomic Nervous System
Hypotension (low blood pressure)
No
Yes
Orthostasis (light headed when standing up)
No
Yes
Cold hands and feet
No
Yes
Unexplained shaking at night
No
Yes
History of latent bed wetting
No
Yes
Night sweats
No
Yes
Eczema
No
Yes
Upper Airway
Claustrophobia
No
Yes
Heightened gag reflex
No
Yes
Encumbered airway subjectively
No
Yes
Small nasal openings
No
Yes
Enlarged Turbinates
No
Yes
Frequent sore throat (pharyngitis)
No
Yes
Deviated septum
No
Yes
Post nasal drip
No
Yes
Chronic sinus/nasal congestion
No
Yes
Sinusitis (frequent)
No
Yes
Chronic cough or throat clearing
No
Yes
Sinus migraines
No
Yes
Nasal polyps
No
Yes
Halitosis (bad breath)
No
Yes
Frequent nosebleeds
No
Yes
BMI - High/Low
No
Yes
Altered smell
No
Yes
Asthma
No
Yes
Lip/chin strain to close mouth
No
Yes
Rhinitis (frequent)
No
Yes
Nasal Obstruction
No
Yes
Orthodontic History
When treated (Ex:TMD, cosmetic, crowding)
Retreats/Why?
Teeth extracted
No
Yes
History of headgear
No
Yes
History of palatal expansion
No
Yes
Nasal Obstruction Symptom Evaluation (NOSE) Scale
Over the past month, how much of a problem were the following conditions for you?
Not a Problem = 0
Very Mild Problem = 1
Moderate Problem = 2
Fairly Bad Problem = 3
Severe Problem = 4
Nasal congestion or stuffiness
0
1
2
3
4
Nasal blockage or obstruction
0
1
2
3
4
Trouble breathing through my nose
0
1
2
3
4
Trouble sleeping
0
1
2
3
4
Unable to get enough air through my nose during exercise or exertion
0
1
2
3
4
Total Score:
___
NOSE Score:
___