Patient Biographical Information    
Patients under 18 years of age
 
*First Name:  
 Middle Initial:
*Last Name:  
 Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
   
Height:
Weight:
This form being completed by:
Other:
*Main Phone:  
 Cell Phone:
 Email:
   
School:
Grade:
With whom does the patient reside?
Explain Other:
 
Has patient begun puberty:
If patient is a girl, has menstruation begun:
Has the patient grown in the past year or has their shoe size changed recently:
Is patient adopted?
Has either biological parent ever had orthodontic treatment:
Patient's interest in treatment:
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?
If so, when?
Check-up Frequency:
Last Dental Visit:  
 
*Please answer the following questions. (Cannot be left blank.)
  Speech problems/therapy?
  Grind or clench teeth?
  Oral habits (thumb/finger sucking, 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?
  Excessive bleeding following extractions?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Requires premedication?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Frequently chew gum?
  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:
 
*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
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia
  HIV/AIDS
  Hepatitis
  Tonsils/Adenoids Removed
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Handicaps/Disabilities
  Asthma
  Arthritis
  Treated for Emotional Problems
  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 drug allergies or sensitivities that the patient may have:
 
  Parent/Guardian Information    
 
Mother's Information:
*First Name:  
 Middle Initial:
*Last Name:  
 Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Cell Phone:  
*Email:  
 Employer:
*Occupation:  
 Work Phone:
 
Father's Information:
*First Name:  
 Middle Initial:
*Last Name:  
 Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Cell Phone:  
*Email:  
 Employer:
*Occupation:  
 Work Phone:
   
Who will be financially responsible for the treatment?
   
  Financial Party Information    
 
*First Name:  
 Middle Initial:
*Last Name:  
 Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
*Cell Phone:  
*Email:  
   
Relationship to Patient:
If other:
 Employer:
*Occupation:  
 Work Phone:
   
Would you like us to provide you with insurance forms?