Patient Biographical Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
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
Check if the patient is also the person who will be financially responsible for treatment.
*
First Name:
Middle Initial:
*
Last Name:
*
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*
Email:
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
Years at address?
Previous Address (if less than 3 years)
*
Cell Phone:
2nd Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone:
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company below:
Secondary insurance benefit?
No
Yes
Subscriber Name:
Subscriber Employer:
Subscriber ID#/SSN:
Subscriber DOB:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient 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.
*
Speech problems/therapy?
No
Yes
*
Clench or Grind Teeth?
No
Yes
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Discomfort from teeth or gums?
No
Yes
*
Pain, tenderness or noise in either jaw?
No
Yes
*
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats?
No
Yes
*
Brush teeth daily?
No
Yes
*
Floss teeth daily?
No
Yes
*
Fluoride treatments?
No
Yes
*
Mouth breathing?
No
Yes
*
Snores during sleep?
No
Yes
*
Requires premedication
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
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
No
Yes
*
Tuberculosis/Lung Disease
No
Yes
*
Pneumonia
No
Yes
*
Liver Disease
No
Yes
*
Kidney Disease
No
Yes
*
Heart Attack/Stroke
No
Yes
*
Heart Disease
No
Yes
*
Congenital Heart Defect
No
Yes
*
Heart Murmur
No
Yes
*
Hemophilia
No
Yes
*
Hypertension/High Blood Pressure
No
Yes
*
Prolonged Bleeding/Transfusion
No
Yes
*
Anemia
No
Yes
*
HIV/AIDS
No
Yes
*
Hepatitis
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
*
Cancer
No
Yes
*
Family History of Cancer
No
Yes
*
Received Radiation Treatment
No
Yes
*
Growth Problems
No
Yes
*
Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Latex/Metal Allergy
No
Yes
*
Nervous Disorders
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Diabetes
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Asthma
No
Yes
*
Arthritis
No
Yes
*
Treated for Emotional Problems
No
Yes
*
Ever Been Hospitalized
No
Yes
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?