Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
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

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Employer:
Occupation:
Length of Employment:
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?

Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
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
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Airway Questionnaire

Daytime Symptoms

Are you frequently sick (Ex: colds, flu)
Fatigue
Morning Headaches
Myalgia-Muscle aches, pains, soreness
Difficulty concentrating
Need caffeine throughout the day
Frequent neck soreness
TMD pain
Forgetfulness

Sleep Disturbances

Sleep Positions
Regular use of sleep aids
Frequent nightly awakenings
Difficulty initiating sleep
Insomnia (difficulty maintaining sleep)
Nighttime bathroom trips
Bruxism, Teeth Grinding, Clenching
Restless leg syndrome
Unrefreshed sleep
GERDS/acid reflux
Snoring
Light Sleeper
Dry Mouth at night or awakening (over breathing)
Chapped lips

Functional Somatic Syndrome

Depression
Chronic Fatigue Syndrome
Irritable Bowel Syndrome
Fibromyalgia
Polysomatic Disorder
Mood Swings/Irritability
Anxiety/Panic Attacks

Autonomic Nervous System

Hypotension (low blood pressure)
Orthostasis (light headed when standing up)
Cold hands and feet
Unexplained shaking at night
History of latent bed wetting
Night sweats
Eczema

Upper Airway

Claustrophobia
Heightened gag reflex
Encumbered airway subjectively
Small nasal openings
Enlarged Turbinates
Frequent sore throat (pharyngitis)
Deviated septum
Post nasal drip
Chronic sinus/nasal congestion
Sinusitis (frequent)
Chronic cough or throat clearing
Sinus migraines
Nasal polyps
Halitosis (bad breath)
Frequent nosebleeds
BMI - High/Low
Neck Size (male>17/female>16)
Altered smell
Asthma
Lip/chin strain to close mouth
Rhinitis (frequent)
Nasal Obstruction
Breathing pattern: Nasal Open/Mouth
Noted Hyper nasality

Orthodontic History

When treated (Ex:TMD, cosmetic, crowding)
Retreats/Why?
Teeth extracted
History of headgear
History of palatal expansion
History of functional appliances