*First Name
Middle Initial
*Last Name
Nickname
*Birthdate
*Gender
*Address
*City
*State
*Zip
*Main Phone
2nd/Cell Phone
Email
Social Security #

List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

*First Name
Middle Initial
*Last Name
Relationship to Patient
*Birthdate
*Address
*City
*State
*Zip
Email
*Main Phone
2nd/Cell Phone
Social Security #
Work Phone #
Employer

Spouse or Other Parent's First Name
Middle Initial
*Last Name
Social Security #
*Birthdate
Relationship to Patient
Employer
Work Phone #
Policy Holder's Name
Relationship to Patient
Policy Holder's Employer:
Insurance Company
Subscriber ID #
Group No.
Insurance Co. Address
City
State
Zip
Insurance Co. Phone No.
*Birthdate
Do you have dual dental coverage?
  If so, please name the Insurance Company below:

Policy Holder's Name
Relationship to Patient
Policy Holder's Employer:
Insurance Company
Subscriber ID #
Group No.
Insurance Co. Address
City
State
Zip
Insurance Co. Phone No.
*Birthdate
Name of nearest relative not living with you
Complete Address
Phone
Relationship to Patient
Dentist Name
Check-up Frequency
Last Dental Visit
*Main Phone
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the patient need to premedicate prior to dental visit?
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.
Clench or Grind 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?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Brush teeth daily?
Floss teeth daily?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Have you been treated for TMJ?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name
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?
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Other
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
Heart Disease
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack / Stroke
Hemophilia
Hypertension / High Blood Pressure
Anemia / Blood Disorder
HIV / AIDS
Diabetes
Tuberculosis or Lung Disease
Cancer
Received Radiation Treatment
Nervous Disorders
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory Problems / Emphysema
Sexually Transmitted Disease
Low Blood Pressure
If any of the above medical questions were answered 'Yes' , please explain: