Confidential Patient Information
*
First Name:
Middle Initial:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Email:
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?
*
How else did you hear about our office?
None
My Dentist
Friend/Family (Please Name)
Social Media (Please Name)
Advertisement (Please Name)
Internet Search
Insurance
Other (Please Name)
Please Name:
Responsible 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:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Other Responsible Party
Check if the second responsible party is also 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:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Birthdate:
Subscriber ID #:
Group No.:
Insurance Company:
Insurance Co. Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Birthdate:
Subscriber ID #:
Group #:
Insurance Company:
Insurance Co. Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Insurance Co. Phone No.:
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
*
Speech problems/therapy?
No
Yes
*
Grind or clench teeth?
No
Yes
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Discomfort from teeth or gums?
No
Yes
*
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats?
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 congenitally missing or extra permanent teeth?
No
Yes
*
Chipped or injured permanent teeth?
No
Yes
*
Teeth sensitive to hot or cold?
No
Yes
*
Previous periodontal (gum) treatment?
No
Yes
*
Abnormal swallowing (and/or tongue thrust)?
No
Yes
*
Frequent canker sores or cold sores?
No
Yes
*
Is all dental work completed at this time?
No
Yes
*
History of jaw joint problems?
No
Yes
*
Have you been treated for "TMJ"?
No
Yes
*
Has jaw ever locked?
No
Yes
*
Notice clicking or popping in jaw joint?
No
Yes
*
Do you clench your teeth?
No
Yes
*
Difficulty chewing or opening mouth?
No
Yes
*
Pain or tenderness in either jaw joint?
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:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
*
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
*
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
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
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:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Parent/Guardian 1 Name:
Parent/Guardian 1 Relationship to Patient:
Father
Mother
Step-parent
Other
Parent/Guardian 2 Name:
Parent/Guardian 2 Relationship to Patient:
Father
Mother
Step-parent
Other
Are the Parents:
Married
Separated
Divorced
Re-married
Widowed
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