Confidential Patient Information    
*First Name:
Middle Initial:
*Last Name:
*Birthdate:    
*Gender:
Nickname:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell Phone:
Email:
   
*Father's First Name:
*Father's Last Name:
*Cell Phone:
*Email:
Address:    
*Mother's First Name:
*Mother's Last Name:
*Cell Phone:
*Email:
Address:   
If patient is a minor, who does the patient live with?   
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?     If other:  
  Confidential Financial Party Information    
 
*First Name:
*Last Name:
Marital Status:
Relationship to Patient:
   
*Home Phone:
Cell:
Email:
*Address:
*City:
*State:
*Zip:
   
Employer:
Occupation:
Work Phone #:
Spouse or Other Parent's First Name
Last Name:
Marital Status:
Relationship to Patient:

Home Phone:
Cell:
Email:
Address:
City:
State:
Zip:

Employer:
Occupation:
Work Phone #:
  Dental Insurance Information    
Primary Dental Insurance
*Policy Holder's Name/Subscriber's Name:
*Subscriber ID # or SS #:
*Subscriber's Birthdate:
Relationship to Patient:
*Insurance Company:
Group No.:
Insurance Co. Phone No.:
*Policy Holder's Employer:
If you have dual dental coverage, please name the Insurance Company below:
Secondary Dental Insurance
*Policy Holder's Name/Subscriber's Name:
*Subscriber ID # or SS #:
*Subscriber's Birthdate:
Relationship to Patient:
*Insurance Company:
Group No.:
Insurance Co. Phone No.:
*Policy Holder's Employer:
  Emergency Information    
*Name of nearest relative not living with you:
Complete Address:
*Phone:
Relationship to Patient:
  Dental History     
*Dentist Name:
Address:
City:
State
Zip:
Phone:
Check-up Frequency:   
Last Dental Visit:
Is all dental work complete?
*Has the patient had an orthodontic consult or treatment?
 
If so, when?
With whom?
What is the patient's main orthodontic concern?
Does the Patient need to premedicate prior to dental visit?  
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot leave blank.
Speech problems/therapy?
Oral habits (thumb/finger sucking, lip/nail biting)?
Abnormal swallowing (tongue thrust)?
Snores during sleep?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Teeth sensitive to hot or cold?
Chipped or injured permanent teeth?
Problems with food trapped between teeth?
Teeth that irritate tongue, cheek, lip, etc?
Frequent sore throats?
Frequent canker sores or cold sores?
Floss teeth daily?
Previous periodontal (gum) treatment?
Have wisdom teeth been removed?
Any missing or extra permanent teeth?
Previous root canal therapy?
Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:
TMJ (Temporomandibular Joint) History
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot leave blank.
Clench teeth? Neck and shoulder pain?
Grind teeth? Soreness in your face or around your ears?
Jaw joint popping or clicking? Ringing in the ears?
Jaw joint soreness? Frequent headaches? (4x a week or more)
Locking of jaw? Frequent gum chewing?
Difficulty in chewing or opening your mouth? Previous TMJ treatment?
Injuries/Trauma to face or jaw?
If any of the above TMJ questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Phone:
Date of Last Physical:
Patient Health:
Has there been any change in the patient's general health within the last year?   
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?   
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-prescription) and for what conditions?
*Allergies or drug reaction to:
Latex Naproxen (Aleve)
Nickel Ibuprofen (Motrin/Advil)
Antibiotics   What type?  Tylenol  
Food           What type?   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 leave blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Large Tonsils
Sinus trouble
Substance abuse problem (past or present)
Prosthetic joints
Chronic fatigue
   
   
   
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Persistant cough
Bisphosphonates Use
  --Past or Present
FEMALES: Are you pregnant
   
If any of the above medical questions were answered 'Yes' , please explain:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
Father's Height
Mother's Height:
School:
Grade:
*If patient is a girl, has menstruation begun:  When? 
*If patient is a boy, has their voice changed or have facial hair:   When?  
*Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment: