Patient Biographical Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Gender:   Male Female
*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
Check if the patient is also the person who will be financially responsible for treatment.
*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? NoYes If so, please name the Insurance Company below: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other 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? NoYes If so, please name the Insurance Company below: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Subscriber DOB:   Subscriber ID#:	Social Security #: Employer: Occupation: Length of Employment: Work Phone #:         Group #: Ins. Co. Phone #:

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 consultation or treatment? NoYes 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.
NoYes Flouride Allergy   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 Pain, tenderness or noise in either jaw   NoYes Frequent headaches   NoYes Neck/shoulder pain   NoYes Frequent sore throats	NoYes Had Teeth Extracted in the Past   NoYes Brush teeth daily   NoYes Floss teeth daily   NoYes Fluoride treatments   NoYes Mouth breathing   NoYes Snores during sleep   NoYes Requires premedication for dental appointments   NoYes Any missing or extra permanent teeth   NoYes 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: 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.
NoYes Rheumatic Fever   NoYes Tuberculosis/Lung Disease   NoYes Pneumonia   NoYes Liver Disease   NoYes Kidney Disease   NoYes Heart Attack/Stroke   NoYes Multiple Sclerosis   NoYes Heart Disease   NoYes Congenital Heart Defect   NoYes Heart Murmur   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Transfusion   NoYes Anemia   NoYes HIV/AIDS   NoYes Hepatitis   NoYes Tonsils/Adenoids Removed   NoYes Cerebral Palsy   NoYes Autism   NoYes Undergone or Currently Undergoing Bisphosphonate Treatment	NoYes Cancer   NoYes Family History of Cancer   NoYes Received Radiation Treatment   NoYes Growth Problems   NoYes Endocrine Problems   NoYes Hormone Therapy   NoYes Prolonged Bleeding   NoYes Latex Allergy   NoYes Metal Allergy   NoYes Nervous Disorders   NoYes Bone Disorders/Bone Loss   NoYes Diabetes   NoYes Seizures/Epilepsy   NoYes Handicaps/Disabilities   NoYes Asthma   NoYes Arthritis   NoYes Treated for Emotional Problems   NoYes Ever Been Hospitalized   NoYes ADD/ADHD   NoYes 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?