Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell 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:
* Address:
* City:
* State:
* Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics? If so, please name the Insurance Company:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:

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.
* Speech problems/therapy?
* Grind or clench teeth?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* 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:
Address:
City:
State:
Zip:
Date of last Physical:
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities 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.
* 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
* Tonsils/Adenoids Removed
If you are pregnant, what is your due date?
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex/Metal Allergy (anyone in the household)
* 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:

Patients Under 18

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:
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:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment: