Patient Biographical Information

* First Name:
* Last Name:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Cell Phone:
2nd Phone:
* Email:
Social Security #:

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?

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
Relationship to Patient:
* Email:
* City:
* State:
* Zip:
Years at address?
Previous Address (if less than 3 years)
* Cell Phone:
2nd Phone:
Social Security #:
Length of Employment:
Work Phone:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Secondary insurance benefit?
Subscriber Name:
Subscriber Employer:
Subscriber ID#/SSN:
Subscriber DOB:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
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.
* Speech problems/therapy?
* Clench or Grind Teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Neck/shoulder pain?
* Frequent sore throats?
* Brush teeth daily?
* Floss teeth daily?
* Fluoride treatments?
* Mouth breathing?
* Snores during sleep?
* Requires premedication
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:

List any medications currently being taken by the patient:
List any drug allergies or sensitivites that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be 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
* Hepatitis
* Tonsils/Adenoids Removed
* 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
* Arthritis
* Treated for Emotional Problems
* Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:

Sleep Apnea Questionnaire

Do you have difficulty falling asleep or staying asleep?
Do you snore?
Are you frequently tired during the day?
Are you aware or have you been told that you stop breathing during sleep?
Is your sleep unrefreshing?