Confidential Patient Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?   
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?
  Confidential Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
Marital Status:
How long at this address?  
*Own or Rent?  
*Main Phone:  
2nd/Cell Phone:
Email:
*Birthdate:    
Relationship to Patient:
*Address:  
*City:  
*State:  
*Zip:  
Previous Address (less than 3 years)
Social Security #:  
Employer:  
Occupation:  
Length of Employment:  
Work Phone #:
Spouse or Other Parent's First Name
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:  
Length of Employment:
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Primary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Policy Holder's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
  Emergency Information    
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
  Dental History     
Dentist Name:
Check-up Frequency:   
Last Dental Visit:  
Has the patient had an orthodontic consultation or treatment?
If so, when?
By whom?
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?
  Oral habits (thumb/finger sucking, lip/nail biting)?
  Injury to face, jaw, teeth or mouth?
  Discomfort from teeth or gums?
  Clench or Grind Teeth?
  Pain, tenderness or noise in either jaw joint?
  Frequent headaches/earaches?
  Neck/shoulder pain?
  Does jaw joint ever get "stuck", "locked", or "go out"?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Does the Patient need to premedicate prior to dental visit?
  Any missing or extra permanent teeth?
  Bleeding gums?
  Other periodontal (gum) problems?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
Patient Health:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?     
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?     
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies 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
  Pneumonia
  Liver Disease
  Kidney Disease/Jaundice/Hepatitis
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Damaged/Artificial Heart Valve
  Heart Murmur
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia / Blood disorder
  HIV/AIDS
  Sexually Transmitted Disease
  Tonsils/Adenoids Removed
  Chew or Smoke Tobacco
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Thyroid / Endocrine Problems
  Hormone Therapy
  Metal/Latex Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Bone Fractures/Trauma to face/jaw
  Diabetes
  Seizures / Epilepsy / Neurological Disease
  Handicaps/Disabilities
  Asthma/Sinus Problems
  Arthritis/Joint Problems/Prosthetic Joints
  Treated for Emotional Problems
  Ever been Hospitalized
  FEMALES: Are you pregnant
  Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
Please Provide any additional information that you feel would be helpful in the diagnosis and treatment of your condition.
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment:
 
 
 
  I certify that I have read and understood the Privacy Practices Notice posted on the Lenz Orthodontics website (or      submitted via e-mail) and know that I am entitled to receive this notice in written form at my request.