Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
School:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
  If Patient Is A Minor, Please Complete This Section    
Who has legal custody of the patient:
Mother's Information:  
Name:
Home Phone:
Marital Status:
Work Phone:
Father's Information:
Name:
Home Phone:
Marital Status:
Work Phone:
Please list the name and birthdate of any siblings:
  Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
How long at this address:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Relationship to Patient:
Subscriber DOB:  
Subscriber ID#:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
   
   
Group #:
Ins. Co. Phone #:
Spouse
First Name:  
Middle Initial:  
Last Name:  
How long at this address:  
Address:
City:
State:
Zip:
Main Phone:  
2nd/Cell Phone:  
Email:  
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Relationship to Patient:
Subscriber DOB:  
Subscriber ID#:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
   
   
Group #:
Ins. Co. Phone #:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultation or treatment?
If so, when?  
Has any member of your Family had orthodontic treatment?
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.
  Flouride Allergy
  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
  Had Teeth Extracted in the Past
  Brush teeth daily
  Floss teeth daily
  Fluoride treatments
  Mouth breathing
  Snores during sleep
  Requires premedication for dental appointments
  Any missing or extra permanent teeth
  Apprehensive about dental care
If any of the above dental questions were answered 'Yes', please explain:
Is there any other information we should know about?
 
   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
  Multiple Sclerosis
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Hemophilia
  Hypertension/High Blood Pressure
  Transfusion
  Anemia
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  Cerebral Palsy
  Autism
  Undergone or Currently Undergoing Bisphosphonate Treatment
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Prolonged Bleeding
  Latex Allergy
  Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Handicaps/Disabilities
  Asthma
  Arthritis
  Treated for Emotional Problems
  Ever Been Hospitalized
  ADD/ADHD
  Any congenital (that the patient was born with) problems
If any of the above medical questions were answered 'Yes' , please explain:
Is there any other information we should know about?