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 name and birthdate of any siblings:
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
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
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:
Demographics and Growth
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
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
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Airway Questionnaire
While Sleeping Does Your Child...
Snore more than half the time?
No
Yes
Don't Know
Always Snore?
No
Yes
Don't Know
Snore Loudly?
No
Yes
Don't Know
Have heavy or loud breathing?
No
Yes
Don't Know
Have you ever...
Witnessed your child stop breathing at night?
No
Yes
Don't Know
Does your child...
Tend to breathe through the mouth during the day?
No
Yes
Don't Know
Have a dry mouth on waking up in the morning?
No
Yes
Don't Know
Occasionally wet the bed?
No
Yes
Don't Know
Wake up feeling un-refreshed in the morning?
No
Yes
Don't Know
Have a problem with sleepiness during the day?
No
Yes
Don't Know
Has a teacher or other supervisor commented that your child appears sleepy during the day?
No
Yes
Don't Know
Is it hard to wake your child up in the morning?
No
Yes
Don't Know
Does your child wake up with headaches in the morning?
No
Yes
Don't Know
Did your child stop growing at a normal rate at any time since birth?
No
Yes
Don't Know
Is your child overweight?
No
Yes
Don't Know
This child often...
Does not seem to listen when spoken to directly
No
Yes
Don't Know
Has difficulty organizing tasks?
No
Yes
Don't Know
Is easily distracted by extraneous stimuli?
No
Yes
Don't Know
Fidgets with hands or feet or squirms in seat
No
Yes
Don't Know
Is "on the go" or often acts as if "driven by a motor"
No
Yes
Don't Know
Interrupts or intrudes on others (e.g. butts into conversations or games)?
No
Yes
Don't Know
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:
___