Please complete all applicable biographical, financial, health, dental and sleep sections below. Please be sure to sign the Notice of Privacy Practices. Thank you and we look forward to meeting you and starting your orthodontic journey!

Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Main Phone:
Cell Phone:
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:
Relationship to Patient:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company:
Length of Employment:
Work Phone:

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
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. Cannot be blank.
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?
Requires premedication?
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:
Please list any medications currently being taken by the patient (include non-prescription):
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. Cannot be blank.
Anemia or blood disorder?
Arthritis or joint problems?
Bisphosphonates (Fosamax, Boniva)?
Bone disorders or loss?
Cancer in family history?
Emotional problems treatment?
Endocrine problems?
Growth problems?
Handicaps or disabilities?
Heart attack or stroke?
Heart defect (congenital)?
Heart disease?
Heart murmur?
High blood pressure or hypertension?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
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:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

Has patient begun puberty?
If patient is a girl, has menstruation begun?
If patient is a boy, has their voice changed or have facial hair?
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:

Children only: Pediatric Sleep Questionnaire

While sleeping does your child...
snore more than half the time?
always snore?
snore loudly?
Have 'heavy' or loud breathing?
have trouble breathing, or struggle to breathe?
Have you ever...
seen your child stop breathing during the night?
Does your child...
tend to breathe through the mouth during the day?
have a dry mouth on waking up in the morning?
occasionally wet the bed?
wake up feeling unrefreshed in the morning?
have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Does your child wake up with headaches in the morning?
Did your child stop growing at a normal rate at any time since birth?
Is your child overweight?
This child often...
does not seem to listen when spoken to directly?
has difficulty organizing task and activities?
is easily distracted by extraneous stimuli?
fidgets with hands or feet or squirms in seat?
is 'on the go' or often acts as if 'driven by a motor'?
interrupts or intrudes on others (e.g. butts into conversations or games)?
Total number of 'Yes' responses:

Adults Only: STOP-BANG Adult Sleep Apnea Screening Questionnaire

Do you Snore Loudly (loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
Do you often feel Tired, Fatigued, or Sleepy during the daytime (such as falling asleep during driving or talking to someone)?
Has anyone Observed you Stop Breathing or Choking/Gasping during your sleep?
Do you have or are being treated for High Blood Pressure?

Body Mass Index more than 35 kg/㎡?
Height: Weight:
Age older than 50?
Neck Size Large? (Measured around Adams apple)
For male, is your shirt collar 17 inches / 43cm or larger? For female, is your shirt collar 16 inches / 41cm or larger?
Gender = Male?

Notice of Privacy Practices

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