*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Social Security #:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Work Phone:
2nd/Cell Phone:
Patient's Email:

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?
*First Name:
Middle Initial:
*Last Name:
Relationship to Patient:
*Address:
*City:
*State:
*Zip:
How long at this address?
*Main Phone:
Work Phone #:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse's Name:
Spouse's Occupation:
Spouse's Work Phone:
Spouse's Cell Phone:
Parents' marital status:
With whom does the patient reside?
Legal Guardian:
If you have insurance that covers orthodontics -- please complete:
Name of Insurance Company:
Group #:
Name of Policy Holder:
Policy Holder Birthdate:
Subscriber ID#:
Secondary insurance that covers orthodontics -- please complete:
Name of Insurance Company:
Group #:
Name of Policy Holder:
Policy Holder Birthdate:
Subscriber ID#:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
 
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?

Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?
Grind or clench teeth at night or habitually?
Oral Habits?
Injury to face, jaw, teeth, or mouth?
Discomfort from teeth or gums?
Pain in or near your ears?
Frequent Headaches?
Neck/shoulder pain?
Frequent sore throats?
Constant sore or bleeding gums?
Difficulty chewing or swallowing food?
Brush teeth daily??
Floss Teeth Daily?
Use fluoride rinse daily?
Mouth Breathing?
Snores during sleep?
Antibiotic before dental treatment?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently chews gum?
Had any teeth removed?
Clicking jaw joint when opening/closing?
Pain or tenderness in either jaw?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
Is patient presently under a physician's care? If yes, please explain below:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Stomach or Intestinal Disease
Yellow Jaundice or Hepatitis
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Rheumatism or Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
Tonsils/Adenoids Removed
Operations or Injuries of Head or Neck
History of fainting
If female, are you pregnant?
If any of the above medical questions were answered 'Yes' , please explain:
Are there any medical conditions we have not discussed that you feel we should be made aware of?
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Father/Guardian 1 Email:
Mother/Guardian 2 Email:
Father's Height:
Mother's Height:
Patient's Hobbies/Interests:
Sports:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
Age:
If patient is a boy, has their voice changed or have facial hair:
Has the patient experienced a sudden increase in height:
Does any member of the family have similar arrangement of teeth or jaws?
Has any member of the family had orthodontic treatment?
If yes, who/whom?
Who first noticed the need for orthodontic treatment?
                     Other:      
Are parents interested in having orthodontic treatment:
           
Is the patient concerned about the appearance of his/her teeth?
Has the patient ever been teased about the appearance of his/her teeth?
Is patient aware of/or concerned about his/her orthodontic problem?
What is the patient's attitude toward wearing orthodontic appliances?