Patient Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Gender:
Male
Female
Other
Social Security #:
Nickname (if applicable):
Email:
Cell Phone:
Main Phone:
Address:
City:
State:
Zip:
If patient is a minor, who does the patient live with?
Both Parents
Mother
Father
Self
Other
Employer?
School?
Whom may we thank for referring you?
Please let us know other family members seen by Dr. Kay Daniel?
Dental / Medical History
Dentist Name:
Last Dental Visit:
Is there still work to be done from last dental check up? If yes, what?
Chief dental / orthodontics complaint?
Does the patient have:
Pain / clicking in the jaw joint?
Usually
Sometimes
Never
A bite that feels uncomfortable or unusual?
Yes
No
Any teeth injured due to an accident?
Yes
No
If yes, please explain:
The following habits are of interest. Please list age the habit was broken:
Thumb Sucking
Grinding Teeth
Lip biting or sucking
Finger Sucking
Clenching Teeth
Tongue thrusting
Responsible Party Information
Patient is a child or parent is a responsible party
Marital Status:
Single
Married
Divorced
Mother's Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Cell Phone:
Employer:
Work Phone:
Father's Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Address:
City:
State:
Zip:
Main Phone:
Email:
Cell Phone:
Employer:
Work Phone:
*If the child's guardian is not the natural parent, please give relationship:
Insurance Information
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Insured's Date of Birth:
SS#:
Policy Holder's Employer:
Subscriber ID:
Insurance Company Name:
Insurance Phone:
Orthodontic History
Has the patient had an orthodontic consult?
Yes
No
Has the patient had an orthodontic treatment?
Yes
No
If yes to either, date?
Doctor?
Physician Name:
Is the patient pregnant or possibly pregnant
Yes
No
Is the patient allergic to Latex?
Yes
No
Is the patient allergic to medication?
Yes
No
If so, what?
Has the patient ever had (Please check all that apply)
Anemia?
Yes
No
Arthritis?
Yes
No
Asthma?
Yes
No
Birth Defects?
Yes
No
Blood Disease?
Yes
No
Bone Disorders?
Yes
No
Cold Sores?
Yes
No
Diabetes?
Yes
No
Endocrine Problems?
Yes
No
Epilepsy?
Yes
No
Head / Face Injury?
Yes
No
Hearing Disorder?
Yes
No
Heart disease?
Yes
No
Heart murmur?
Yes
No
Hepatitis?
Yes
No
Herpes?
Yes
No
HIV or AIDS?
Yes
No
Kidney disease?
No
Yes
Lung Disease?
Yes
No
Mitral Valve Prolapse?
Yes
No
Oral Ulcers?
Yes
No
Previous Surgery?
Yes
No
Rheumatic fever?
No
Yes
Thyroid Problems?
Yes
No
Has the patient ever been diagnosed with any other medical / behavioral / mental condition?
ADD / ADHD?
Yes
No
Autism Spectrum?
Yes
No
Anxiety?
Yes
No
Behavioral Disorder?
Yes
No
Depression / Bi-Polar Disorder?
Yes
No
Emotional Disorder?
Yes
No
Other / Comments
If the patient has been under the care of a physician during the last two years for anything other than routine exams, please explain?
Present drugs or medication?
Respitory History
Does the patient have: (Please check all that apply)
Allergies:
Seasonal
Food
Other:
Breathes through mouth:
Usually
Sometimes
Never
Snore when sleeping:
Usually
Sometimes
Never
Frequent colds:
Usually
Sometimes
Never
Frequent stuffy nose:
Usually
Sometimes
Never
Frequent sore throat / tonsillitis:
Usually
Sometimes
Never
Difficulties chewing / swallowing:
Usually
Sometimes
Never
Received medical treatment from an allergist or ear, nose, and throat specialist?
Yes
No
If yes, when:
By Whom:
Nasal Surgery?
Yes
No
Tonsils Removed?
Yes
No
Adenoids Removed?
Yes
No
AUTHORIZATION & RELEASE
I certify the above information is correct and complete. I understand that providing incorrect or incomplete information can be dangerous to this patient’s health. I agree to be responsible for payment of all services rendered including what is billed to my insurance company. I authorize my insurance company to pay benefits directly to Dr. Daniel’s office. I understand information will be communicated with anyone who accompanies this patient to appointments. I also authorize Dr. Daniel and her staff to perform any form of treatment, medication, or therapy regarding this patient.
Signature (Patient / Parent / Guardian):
Relationship to Patient:
By typing my name above I am electronically signing this form.