Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security # or Driver's License:

Please list the names of any friends or family currently in the practice:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
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:
Cell Phone:
Social Security # or Driver's License:
Employer:
Occupation:
Work Phone:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security # or Driver's License:
Employer:
Occupation:
Work Phone:

Dental Insurance Information

Insurance Company Name:
Policy Holder's Name:
Subscriber ID:
Birthdate:

Do you have dual dental coverage?
(If yes, complete information below)
Insurance Company Name:
Policy Holder's Name:
Subscriber ID:
Birthdate:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Does the Patient need to premedicate prior to dental visit?
What is the patient's main orthodontic concern?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Apprehensive about dental care?
Brush teeth daily?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Fluoride treatments?
Frequently chew gum?
Frequent headaches?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Missing or extra permanent teeth?
Mouth breathing?
Neck or shoulder pain?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Snores during sleep?
Speech problems or therapy?
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:

Please list any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex?
Metal/Nickel?
Please list any other drug allergies or sensitivities that the patient may have:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past.
Anemia or blood disorder?
Arthritis or joint problems?
Asthma?
Bone disorders or loss?
Cancer?
Cancer in family history?
Diabetes?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
Hemophilia?
Hepatitis?
High blood pressure or hypertension?
HIV or AIDS?
Hormone therapy?
Kidney disease?
Liver disease?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
Ever been hospitalized?
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 age of any siblings:
School:
Grade:
Has the patient grown in the past year or has their shoe size changed recently?
Patient's interest in treatment?
Has either biological parent ever had orthodontic treatment?