7655 Five Mile Road Suite 207 Cincinnati, OH 45230
513-232-4110 Fax: 513-232-4949
info@drromick.com
Patient Biographical Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Gender:   Male Female
*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
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:
*Main Phone:   2nd/Cell Phone: Email: Employer: Occupation: Length of Employment: Work Phone #: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other	Do you have orthodontic insurance? NoYes If so, please name the Insurance Company below: Insurance Phone: Subscriber Name: Subscriber DOB: Social Security #:    Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other

Dental History
Dentist Name: Check-up Frequency: Once per year Twice per year More than twice a year Never Emergencies only Last Dental Visit:	Has the patient had an orthodontic consultant or treatment? NoYes 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.
NoYes  Speech problems/therapy?   NoYes  Grind or clench 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  Bleeding of gums when brushing or flossing?   NoYes  Pain, tenderness or noise in either jaw?   NoYes  Frequent headaches?   NoYes  Neck/shoulder pain?   NoYes  Frequent sore throats?	NoYes  Brush teeth daily?   NoYes  Floss teeth daily?   NoYes  Home fluoride use?   NoYes  Mouth breathing?   NoYes  Snores during sleep?   NoYes  Any missing or extra permanent teeth?   NoYes  Apprehensive about dental care?   NoYes  Frequently Chew Gum?   NoYes  Known allergies to latex or any metals?   NoYes  Baby or permanent teeth removed or extracted?
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: Good Excellent Fair Poor
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. Cannot be blank.
NoYes Rheumatic Fever   NoYes Tuberculosis/Lung Disease   NoYes Pneumonia   NoYes Liver Disease   NoYes Kidney Disease   NoYes Heart Attack/Stroke   NoYes Heart Disease   NoYes Congenital Heart Defect   NoYes Heart Murmur   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Prolonged Bleeding/Transfusion   NoYes Anemia   NoYes Autism	NoYes Cancer   NoYes Family History of Cancer   NoYes Received Radiation Treatment   NoYes Growth Problems   NoYes Endocrine Problems   NoYes Hormone Therapy   NoYes Latex/Metal Allergy   NoYes Nervous Disorders   NoYes Bone Disorders/Bone Loss   NoYes Diabetes   NoYes Seizures/Epilepsy   NoYes Handicaps/Disabilities   NoYes Asthma   NoYes ADD/ADHD
If any of the above medical questions were answered 'Yes' , please explain:
Do you/does the patient have any conditions not listed that we should know about?

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: NoYes Has the patient had a growth spurt recently: NoYes Patient's interest in treatment: Patient wants treatment Patient unwilling, but agrees Treatment only if necessary Patient un-cooperative Has either biological parent ever had orthodontic treatment: Don't Know Yes No Please list any other concerns you have regarding orthodontic treatment