Patient Biographical Information
Patients under 18 years of age
*First Name:    Middle Initial: *Last Name:    Nickname:	*Birthdate:     *Gender:   Male Female
*Address:   *City:   *State:   *Zip:       Height: Weight: This form being completed by: Mother Father Guardian Other Other: *Main Phone:    Cell Phone:  Email:     School: Grade: With whom does the patient reside? Parents Mother Father Other Explain Other:   Has patient begun puberty: NoYes If patient is a girl, has menstruation begun: NoYes Has the patient grown in the past year or has their shoe size changed recently: NoYes Is patient adopted? NoYes Has either biological parent ever had orthodontic treatment: Don't Know Yes No Patient's interest in treatment: Patient wants treatment Patient unwilling, but agrees Treatment only if necessary Patient un-cooperative What is the patients main orthodontic concern? List any sports, hobbies, or musical instruments played: Please list the name and birthdate of any siblings: Please list the names of any friends or family currently in the practice: Whom may we thank for referring you to our practice?     Dental History        Dentist Name: Address: City: State: Zip: Has the patient had an orthodontic consultant or treatment? NoYes If so, when? Check-up Frequency: Once per year Twice per year More than twice a year Never Emergencies only Last Dental Visit:     *Please answer the following questions. (Cannot be left blank.)   NoYes Speech problems/therapy?   NoYes Grind or clench teeth?   NoYes Oral habits (thumb/finger sucking, 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 Excessive bleeding following extractions?   NoYes Brush teeth daily?   NoYes Floss teeth daily?   NoYes Fluoride treatments?   NoYes Mouth breathing?   NoYes Snores during sleep?   NoYes Requires premedication?   NoYes Any missing or extra permanent teeth?   NoYes Apprehensive about dental care?   NoYes Frequently chew gum?   NoYes Trouble associated with previous dental work?   Please provide necessary explanations below:      Medical History        Physician Name: Address: City: State: Zip: Date of last Physical:   Patient Health: Good Excellent Fair Poor   *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 Heart Disease   NoYes Congenital Heart Defect   NoYes Heart Murmur   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Prolonged Bleeding/Transfusion   NoYes Anemia   NoYes HIV/AIDS   NoYes Hepatitis   NoYes Tonsils/Adenoids Removed   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 Arthritis   NoYes Treated for Emotional Problems   NoYes Ever Been Hospitalized   If any of the above medical questions were answered 'Yes' , please explain: Is patient currently under the care of a physician? Please explain: List any medications currently being taken by the patient: List any allergies or sensitivities that the patient may have:     Parent/Guardian Information       Mother's Information: *First Name:    Middle Initial: *Last Name:    Marital Status: Married Divorced Widowed Single *Address:   *City:   *State:   *Zip:   *Main Phone:   *Cell Phone:   *Email:    Employer: *Occupation:    Work Phone:   Father's Information: *First Name:    Middle Initial: *Last Name:    Marital Status: Married Divorced Widowed Single *Address:   *City:   *State:   *Zip:   *Main Phone:   *Cell Phone:   *Email:    Employer: *Occupation:    Work Phone: Who will be financially responsible for the treatment? Parents Father Mother Other       Financial Party Information       *First Name:    Middle Initial: *Last Name:    Marital Status: Married Divorced Widowed Single *Address:   *City:   *State:   *Zip:   *Main Phone:   *Cell Phone:   *Email:       Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other If other:  Employer: *Occupation:    Work Phone:     Would you like us to provide you with insurance forms? NoYes             Signature:    Date: