Patient Information: Patients Under 18 Years of Age
Legal First Name:
Middle Initial:
Legal Last Name:
Nickname:
Sex:
M
F
Pronoun Preference:
He
She
They
Address:
City:
State:
Zip:
Birthdate:
Age:
Home Phone:
Email:
Cell Phone:
Text Appointment Confirmation:
Yes
No
Do you give us permission to text or call this number to leave a message or voicemail?
Yes
No
School:
Grade:
Sports/Hobbies:
Names & Ages of Siblings:
Whom may we thank for referrring you to our office? Check all that apply.
Dentist
Friend
Internet
Physician
Other:
Responsible Party Information
1. First Name:
Middle Initial:
Last Name:
Address (If different from above):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Employer:
Years:
2.. First Name:
Middle Initial:
Last Name:
Address (If different from above):
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Employer:
Years:
Dental Insurance Information
1. Subscriber's Name:
ID # or Social Security #:
Subscriber's DOB:
Group #:
Subscriber's Address:
City:
State:
Zip:
Insurance Company:
Insurance Address:
Insurance Phone:
2. Subscriber's Name:
ID # or Social Security #:
Subscriber's DOB:
Group #:
Subscriber's Address:
City:
State:
Zip:
Insurance Company:
Insurance Address:
Insurance Phone:
Emergency Contact Information
Name of nearest relative NOT living with you:
Phone:
Relationship to you:
Medical History
Physician:
Date of Last Visit (month/year):
Phone:
City:
Are you allergic to any medications?
Yes
No
If yes, what?
Have you had any operations?
Yes
No
If yes, what?
Ever been involved in a serious accident?
Yes
No
If yes, please briefly explain the accident:
Have you seen a physician in the last 12 months?
Yes
No
For what reason?
Latex Allergy?
Yes
No
If yes, what is your reaction?
Other allergies?
Yes
No
Please list:
What do you do to relieve symptoms of allergies (medications, nasal spray, etc)?
Are you taking bisphosphonates?
Yes
No
Other medications?
Yes
No
Please list:
Please check any of the following conditions that apply to the patient now
or in the past:
Abnormal Bleeding/Hemophilia
Acid Reflux
Anemia
Arthritis
Asthma or Hay Fever
Do you take medication?
Y
N
Bone Disorders
Chemotherapy
Chronic Ear Infections (as adult or child)
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders or Discomfort
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
HIgh Blood Pressure
HIV/AIDS
Irritable Bowel Syndrome
Kidney Problems
Leaky Gut
Metal Sensitivity
Nervous Disorders
Obstructive Sleep Apnea (sleep disordered breathing)
Pneumonia
Pregnancy
Prolonged Bleeding
Radiation Therapy
Rheumatic Fever
Tuberculosis
Tumor/Cancer
None
Other
If other, what?
Have you seen any of the following practitioners?
ENT
Provider:
Naturopath
Provider:
Allergist
Provider:
Chiropractor
Provider:
Oral Surgeon
Provider:
Acupuncturist
Provider:
Sleep Physician
Provider:
Myofunctional Therapist
Provider:
Speech Therapist
Provider:
Dental History
General/Pediatric Dentist:
Date of Last Visit (month/year):
City:
Phone:
How many times per day do you brush?
Hardly ever
A few times/week
At least 1x/day
At least 2xday
How often do you floss?
Hardly ever
A few times/week
At least 1x/day
At least 2x/day
Has anyone ever shown you how to properly brush or floss?
Y
N
Unsure
Do you argue with your parents about brushing?
Y
N
Sometimes
Do you need reminders to brush?
Y
N
Sometimes
Have you ever had a cavity?
Y
N
Social Concerns
Do you avoid showing your teeth when smiling?
Y
N
Do you avoid photos?
Y
N
Do you feel anxious or unsure of yourself?
Y
N
Do you prefer we NOT discuss jaw structure directly?
Y
N
Have you ever had a negative reaction (emotionally) to dental treatment?
Y
N
Do you prefer extra instructions when learning or experiencing something new?
Y
N
Do you defy instructions or have difficulty following rules?
Y
N
Teeth and Gums
Are you currently in any dental pain?
Y
N
Have you ever had any teeth removed by a dentist?
Y
N
Are your teeth sensitive to temperature or pressure?
Y
N
Do your gums bleed when brushing or flossing?
Y
N
Jaw Joints
Are your jaw muscles tight in the mornings when you wake up?
Y
N
Do you notice clicking or popping of your jaw joints?
Y
N
If yes, is it painful?
Y
N
Do you have episodes of restricted movements with your jaws (jaws locked open or closed)?
Y
N
Do you get frequent headaches?
Y
N
Do you notice ringing in your ears?
Y
N
Growth & Development
Have you experienced any injuries to your jaws or face?
Y
N
If yes, what?
Are you still growing taller or growing out of your shoes/clothes?
Y
N
Have you started your menstral cycle?
Y
N
N/A
If yes, when?
Does late-growth run in your family?
Y
N
If breast fed, was latching difficult?
Y
N
N/A
Speech
Have you been evaluated by a speech language pathologist?
Y
N
Provider:
Do you have any speech concerns?
Y
N
Please detail any information regarding your speech concerns, or what was addressed with your speech language pathologist.
Oral Habits & Eating
Do you chew with your mouth open?
Y
N
Do you clench or grind your teeth during the day?
Y
N
Do you clench or grind your teeth at night?
Y
N
Do you chew with your mouth open?
Y
N
Do you avoid certain foods based on texture?
Y
N
Are you a loud eater?
Y
N
Do you avoid hard or chewy food?
Y
N
Would your eating preferences be considered:
Picky
Average
Adventurous
Do you have any other oral habits?
Check all that apply:
Lip biting
Tongue biting
Nail biting
Thumb/finger sucking
Pacifier use beyond age 3
Sleep Health and Airway
Do you fall asleep quickly?
Y
N
Do you have difficulty falling or staying asleep?
Y
N
Do you wake up easily throughout the night?
Y
N
Do you snore?
Y
N
Do you gasp or choke at night while sleeping?
Y
N
Do you frequently feel tired during the day?
Y
N
Are you an active sleeper (moving a lot or sweating a lot)?
Y
N
Do you have difficulty breathing through your nose (in general)?
Y
N
Can you tolerate light excercise with your lips closed (nasal breathing)?
Y
N
Have you ever been screened for sleep-disordered breathing (ex. obstructive sleep apnea)?
Y
N
Do you wet the bed at night?
Y
N
Is your mouth dry in the morning?
Y
N
Orthodontic History
Have you ever seen an orthodontist?
Y
N
Have you ever had orthodontic treatment?
Y
N
If yes, when:
Which of the following would you like us to emphasize in your initial consultation? Check all that apply.
Appearance of your smile
Appearance of your jaw structure (profile)
Health and function of your bite and teeth
Airway and sleep apnea
Facial pain
Do you have any treatment preferences? Check all that apply.
Invisalign or other removable appliance
Braces
Sleep apnea appliance
Preventative therapy
No preference
Notice of Privacy Acts Consent Form
I understand that I have certain rights given to me under the Health Insurance Portability and Accountability Act (HIPPA) regarding my protected health information. I understand that by signing this consent form, I authorize you to use and disclose my protected health information for the following:
Treatment including that given by all health care providers involved in my care.
Obtaining payment from third party payers including insurance companies and other paying parties.
The day-to-day health care practices of the orthodontic practice.
I have also been informed that I may request a copy of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy or the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care options. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
I understand that I may ask that this consent be revoked but I must do so in writing. However, any use or disclosure that occurred prior to the date is not affected.
I attest to the accuracy of this information and acknowledge that it is my responsibility to notify this office of any medical or contact changes; I authorize release of any information to a third party for insurance claims, education, and/or treatment; I understand that a credit bureau check may be obtained where necessary.
Responsible Party:
Relationship to Patient
Signature:
Date: