Patient Biographical Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Sex: Male Female Age: *Phone:   Cell Phone: Email:
*Address:   *City:   *State:   *Zip:   How long at this address? Social Security #: Are you: Married Separated Divorced Single Widowed Domestic Partner Employer: How long? Occupation: Work phone: May we contact you or leave a message? NoYes Whom may we thank for referring you to our office?

Other Responsible Party Information
*UNLESS OTHERWISE SPECIFIED, YOU ARE CONSIDERED RESPONSIBLE FOR YOUR ACCOUNT
Spouse's Name: Social Security #:	Address: City: State: Zip: How long at this address?
Home Phone: DOB:	Employer: How long? Occupation: Work Phone #: May we contact them or leave a message? NoYes

Dental Insurance Information
Policy Holder: Policy Holder's DOB:   Relationship: Employer:	Group #: Insurance ID#: Insurance company: Ins phone #: Insurance company address:
Do you have dual coverage? NoYes Policy Holder: Policy Holder's DOB:   Relationship: Employer:	If yes: (Please fill below) Group #: Subscriber #: Insurance ID#: Insurance company: Ins phone #: Insurance company address:

Medical History
Height:	Weight:
Have you been in the hospital in the last 2 years? NoYes   Have you been "under the care" of a physician during the past 2 years? NoYes   Have you taken any kind of medication or drugs during the past year? NoYes If yes, please list:	Have you ever had any excessive bleeding requiring special treatment? NoYes   Are you allergic to penicillin, codeine, or any other drugs/medicine? NoYes   Are you allergic to latex or nickel? NoYes If yes, which?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal Bleeding NoYes   Anemia NoYes   Arthritis NoYes   Asthma or Hay Fever NoYes   Autism NoYes   Bone Disorders NoYes   Congenital Heart Lesions NoYes   Persistent or Chronic Cough NoYes   Diabetes NoYes   Dizziness NoYes   Epilepsy NoYes   Heart Murmur (if pre-medication needed) NoYes   Heart Trouble NoYes   Hepatitis/Liver Problems NoYes	Herpes NoYes   High Blood Pressure NoYes   HIV Positive (AIDS) NoYes   Jaundice NoYes   Nervous Disorders NoYes   Psychiatric Treatment NoYes   Radiation or Chemotherapy NoYes   Rheumatic Fever NoYes   Sinus Trouble NoYes   Stroke NoYes   Tuberculosis NoYes   Venereal Disease NoYes   Handicaps/Disabilities NoYes Other:
Have your tonsils and adenoids been removed? NoYes  Females: Are you pregnant? NoYes   Do you smoke? NoYes	Have you had any other serious illnesses/accidents? NoYes If so, describe:

Dental History
Do you vomit, gag, or faint easily? NoYes   Do you have speech problems? NoYes   Are you a daytime mouth breather? NoYes   Do you experience headaches or pain, in or around the ears? NoYes   Have any teeth been injured due to accidents, or falls? NoYes	Have you ever sucked your thumb or fingers? NoYes Until what age?   Do you grind, or clench your teeth while awake? NoYes   Do you grind, grit, or clench your teeth while sleeping? NoYes
Last Dental Visit:   Next Dental Visit:   Dentist's Complete Name: Phone #:	Dentist's Complete Address: City: State: Zip:
Medical Physician's Name:	Address:

NoYes	I hereby consent for any of my images taken by/sent to Crawford Orthodontics to be used for marketing purposes on any Crawford Orthodontics social media sites. I understand that no names or other personally identifying label will be used in conjunction with the images.
I acknowledge that I have read and understood the HIPAA Consent Form