Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Gender:
Birthdate:
Age:
Address:
City:
State:
Zip:
Main Phone:
Dentist:
Physician:

Whom may we thank for referring you to our practice?
What questions would you like answered today?
Person(s) responsible for payment:
Relationship to Patient:

Complete For A Child/Teen Patient

School:
Grade:
Musical Instrument:
Sports:
Hobbies/Interests

Parent/Guardian:
Middle Initial:
Last Name:
Cell Phone:
Main Phone:
Work Phone:
Address (if not the same):
City:
State:
Zip:
Employer:
Email:

Parent/Guardian:
Middle Initial:
Last Name:
Cell Phone:
Main Phone:
Work Phone:
Address (if not the same):
City:
State:
Zip:
Employer:
Email:

Complete For An Adult Patient

Your Employer:
Email:
Work Phone:
Spouse's Employer:
Email:
Work Phone:

Dental Insurance Information

Please use information from your insurance card to complete this section.

Primary

Insurance Company:
Insurance Phone:
Policy Holder's Name:
SSN:
Subscriber D.O.B.:
Employer:

Secondary

Insurance Company:
Insurance Phone:
Policy Holder's Name:
SSN:
Subscriber D.O.B.:
Employer:

Medical History

DOES THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING?
AIDS?
ADHD?
Anemia?
Anxiety?
Arthritis?
Artificial Heart Valve?
Artificial Joints?
Asthma?
Blood Disorders?
Blood Transfusions?
Bruise Easily?
Cerebral Palsy?
Congenital Heart Disease?
COVID-19?
Diabetes?
Emotional Problems?
Epilepsy (Convulsions)?
Frequent Headaches?
Glaucoma?
Heart Murmur/Heart Problems?
Hemophilia?
Hepatitis?
Herpes?
High Blood Pressure?
Kidney Disorders?
Latex Sensitivity?
Liver Disease?
Metal Sensitivity?
Mitral Valve Prolapse?
Respiratory Problems?
Rheumatic Fever?
Snoring or Sleep Apnea?
Thyroid Problems?
Tonsil and/or Adenoid Removed?
Tuberculosis or Lung Disease?
State any reasons why the patient is currently under the care of a physician:
List any drug allergies or sensitivities:
List any medications that the patient is currently taking:
Has the patient been advised to take antibiotics prior to dental procedures?
List any other serious illnesses, operations or diseases not listed above:

Developmental History for Child/Teen

Girls Only

Has patient started monthly cycle?
If yes, age of onset:
If patient is a boy, has their voice changed or have facial hair?

Dental History

Does the patient have a history of any of the following

Bleeding Gums?
Chipped or Injured Permanent Teeth?
Chronic Facial Pain?
Clench or Grind Teeth?
Difficulty Chewing or Swallowing?
Dizziness in Dental Chair?
Frequent Canker Sores?
Injuries to Face or Teeth?
Jaw Joint Pain?
Jaw Joints Pop or Click?
Jaw Locking Open or Closed?
Limitation in Mouth Opening?
Missing or Extra Permanent Teeth?
Mouth Breathing?
Muscle Tenderness in Jaw or Neck?
Nail Biting?
Periodontal Surgery?
Permanent Teeth Removed?
Speech Problems?
Sucks Thumb, Finger, or Lip?
Teeth Sensitivity - Hot/Cold?
Tongue Thrust?
List any dental problems we should know about:
Has the patient had a previous orthodontic consult or treatment? If so, with who?
List the patient's chief concerns and what they would like this orthodontic treatment to accomplish?
Digital Signature: (If minor, parent's signature.)
Date