Confidential Patient Information

First Name:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Cell Phone:
Email:
Whom may we thank for referring you to our practice?

Financial Party Information

First Name:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Cell Phone:

Dental Insurance Information

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Social Security # of Insured:
Policy Holder's Birthdate:
Do you have dual dental coverage?
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Social Security # of Insured:
Policy Holder's Birthdate:

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?
Clench or grind teeth?
Discomfort from teeth or gums?
Frequent headaches?
Frequent sore throats?
History of cold sores, herpetic lesions, canker sores?
History of tonsils/adenoids removed?
Injury to face, jaw, teeth, or mouth?
Mouth breathing?
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:
Physician Phone:
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?
Asthma?
Bisphosphonates (Fosamax, Boniva)?
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?
History of Surgery?
HIV or AIDS?
Hormone therapy?
Ever been hospitalized?
Kidney disease?
Latex or Metal Allergy?
Liver disease, jaundice, or hepatitis?
Nervous disorders?
Pneumonia?
Prolonged bleeding or transfusion?
Radiation treatment?
Rheumatic fever?
Seizures, epilepsy, or neurological disease?
Tuberculosis or lung disease?
FEMALES: Are You Pregnant?
If so, due date?
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:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Who does patient live with?
Anything else we should know?
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?
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Signature:
Date: