Confidential Patient Information
*First Name: Middle Initial: *Last Name: Nickname:	*Birthdate:   *Gender: Male Female
*Address: *City: *State: *Zip: Employer/School:   *Home Phone: Cell Phone: Email: Social Security #: Work/School Phone:   If patient is a minor, please answer the following Father's Name: Mother's Name: Address: Address: City: City: State: State: Zip: Zip: Home Phone Home Phone: Cell Phone: Cell Phone: E-mail: E-mail: Marital Status: Marital Status: Employer: Employer: Work Phone: Work Phone: Who does patient live with?    Select... Father Mother Mother & Father Other Please specify:   Please list the names of any friends or family currently in the practice: List any sports, hobbies, or musical instruments played: How did you hear about our practice?   Select Dentist Family/Friends Website Facebook Drive by/Sign Advertisement Other Please specify:

Emergency Information
Name of nearest relative not living with you:
Address:
City
State:
Zip:
Phone: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other   Confidential Financial Party Information     Check if the patient is also the person who will be financially responsible for treatment.   *First Name: Middle Initial: *Last Name: *Address: *City: *State: *Zip: Marital Status: Select... Single Married Partnered Widowed Divorced Separated How long at this address? *Main Phone: Cell Phone: Email: *Birthdate:   Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Social Security #: Employer: Occupation: Length of Employment: Work Phone #: Spouse's First Name: Middle Initial: Last Name: Social Security #: Employer: Occupation: Birthdate:   Length of Employment: Work Phone #: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other

Dental Insurance Information     Primary Dental Insurance Policy Holder's Name: Birthdate: Insurance Company: Subscriber ID #: Group No.: Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.: Policy Holder's Employer: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Do you have dual dental coverage? NoYes   (If yes, complete information below) Secondary Dental Insurance
Policy Holder's Name: Birthdate: Insurance Company: Subscriber ID #: Group No.: Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.:   Policy Holder's Employer:   Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other
Dental History
Dentist Name: Is all dental work completed?     YesNo Last Dental Visit:	Has the patient had an orthodontic consult or treatment? NoYes 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.
NoYes  Speech problems/therapy NoYes  Clench or grind teeth NoYes Oral habits (thumb/finger sucking, lip/nail biting) NoYes  Injury to face, jaw, teeth or mouth NoYes  Discomfort from teeth or gums NoYes  Pain, tenderness or noise in either jaw NoYes  Frequent headaches NoYes  Neck/shoulder pain NoYes  Chipped or injured permanent teeth NoYes  Previous root canal therapy NoYes  Bad taste/mouth odor NoYes  Abnormal swallowing (tongue thrust)	NoYes  Mouth breathing NoYes  Snores during sleep NoYes  Apprehensive about dental care NoYes  Jaw fractures, cysts, mouth infections NoYes  Frequent canker sores or cold sores NoYes  Problems with food trapped between teeth NoYes  Previous periodontal (gum) treatment NoYes  Teeth sensitive to hot or cold NoYes  Clicking/popping/pain in TMJ(jaw joint)
If any of the above dental questions were answered 'Yes', please explain:

Medical History
Physician Name: Address: City: State: Zip:	Date of Last Physical:
NoYes    Has there been any change in the patient's general health within the last year?
NoYes    Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
NoYes    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-prescirption):
NoYes     FEMALES: Are you pregnant
Allergies or drug reaction to:
NoYes  Latex NoYes  Nickel NoYes  Medications If yes to any allergies, please explain in detail or list anything not mentioned above.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
NoYes  Heart Murmur NoYes  Heart Disease NoYes  Angina NoYes  Liver Disease / Jaundice / Hepatitis NoYes  Kidney Disease NoYes  Heart Attack/Stroke NoYes  Hemophilia NoYes  Hypertension/High Blood Pressure NoYes  Prolonged Bleeding/Transfusion NoYes  Anemia / Blood disorder NoYes  HIV/AIDS NoYes  Tonsils/Adenoids Removed NoYes  Handicaps/Disabilities NoYes  Diabetes NoYes  Growth Problems	NoYes  Tuberculosis or Lung Disease NoYes  Cancer NoYes  ADD/ADHD NoYes  Radiation Treatment NoYes  Hormone Therapy NoYes  Seizures / Epilepsy / Neurological Disease NoYes  Treated for Emotional Problems NoYes  Asthma NoYes  Respiratory problems / Emphysema NoYes  Persistent swollen neck glands NoYes  Low blood pressure NoYes  Persistent cough
If any of the above medical questions were answered 'Yes' , please explain:

Does the patient need to premedicate prior to dental visit?   NoYes

If yes, please explain.

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

I understand that where appropriate, credit bureau reports may be obtained.