Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
Province:
Postal Code:
Main Phone:
Cell Phone:
Email:
If patient is a minor, who is the parent or guardian?
If patient is a minor, who does the patient live with?
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
Province:
Postal Code:
Email:
Main Phone:
Cell Phone:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Dental Insurance Information
Primary Dental Insurance
Policy Holder's Name:
Policy Holder's Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Insurance Company Name:
ID Number/Certificate:
Group Number:
Province:
Postal Code:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Policy Holder's Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Insurance Company Name:
ID Number/Certificate:
Group Number:
Province:
Postal Code:
Emergency Contact Information
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental History
Dentist Name:
Dental Office Name:
Last Dental Visit:
Has all dental work been completed at this time?
No
Yes
Have you ever had an orthodontic consult or treatment?
No
Yes
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.
Abnormal swallowing (tongue thrust)?
No
Yes
Apprehensive about dental care?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Clench or grind teeth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Frequent headaches?
No
Yes
Have wisdom teeth been removed?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Jaw fractures, cysts, or mouth infections?
No
Yes
Missing or extra permanent teeth?
No
Yes
Mouth breathing?
No
Yes
Other periodontal (gum) problems?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Problems with food trapped between teeth/spacing/gaps?
No
Yes
Sleep Apnea?
No
Yes
Speech problems or therapy?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Thumb or finger habit as a child?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name:
Phone:
Clinic Name:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years? If so, what for?
No
Yes
Please list any medications currently being taken by the patient (include non-prescription):
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Angina?
No
Yes
Anemia or blood disorder?
No
Yes
Arteriosclerosis?
No
Yes
Arthritis or joint problems?
No
Yes
Asthma?
No
Yes
Bisphosphonates (Fosamax, Boniva)?
No
Yes
Bone disorders or loss?
No
Yes
Bone fractures or trauma to face or jaw?
No
Yes
Cancer?
No
Yes
Cancer in family history?
No
Yes
Chronic fatigue?
No
Yes
Diabetes?
No
Yes
Mental Illness (ex. Depression)?
No
Yes
Growth problems?
No
Yes
Physical disabilities?
No
Yes
Heart attack or stroke?
No
Yes
Any heart issues?
No
Yes
Blood Disorders?
No
Yes
High blood pressure or hypertension?
No
Yes
Hormone therapy?
No
Yes
Kidney disease?
No
Yes
Liver disease, jaundice, or hepatitis?
No
Yes
Low blood pressure?
No
Yes
Neurological disorders?
No
Yes
Persistent cough?
No
Yes
Persistent swollen neck glands?
No
Yes
Pneumonia?
No
Yes
Prosthetic joints/joint replacement?
No
Yes
Radiation treatment?
No
Yes
Respiratory problems or emphysema
No
Yes
Rheumatic fever?
No
Yes
Seizures, epilepsy, or neurological disease?
No
Yes
Sexually transmitted disease?
No
Yes
Sinus trouble?
No
Yes
Substance abuse problem (past or present)?
No
Yes
Thyroid or endocrine problems?
No
Yes
Tonsils enlarged?
No
Yes
Tonsils or adenoids removed?
No
Yes
Tuberculosis or lung disease?
No
Yes
FEMALES: Are You Pregnant?
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Are there any other medical conditions you feel are important?
Patient Motivation For Orthodontic Treatment
What are the patient's main concerns they feel orthodontics could address?
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
Signature:
Date: