*First Name:
Middle Initial:
*Last Name:
*Main Phone:
2nd/Cell Phone:
Social Security #:
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? (check all that apply)
*Who is Responsible for Account:
*Relationship to Patient:

*First Name:
*Last Name:
Social Security #:
Marital Status:
Relationship to Patient:

First Name:
Last Name:
Social Security #:
Name of Insurance Co.:
Ins. Co. Address:
Ins. Co. Phone #:
Subscriber/Policy #:
Group #:

Secondary Orthodontic Coverage

Name of Insurance Co.:
Ins. Co. Address:
Ins. Co. Phone #:
Subscriber/Policy #:
Group #:
Please authorize consent for our office to do a credit check. This allows our office to extend interest free in house financing to our patients. Your credit status is held in the strictest confidence.

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
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. Cannot be blank.
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?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Sleeps with mouth open?
Snores during sleep?
Requires antibiotic premedication?
Do you have any limitations laying horizontal in a dental chair so you can have dental work performed?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
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. Cannot be blank.
Rheumatic Fever
Tuberculosis/Lung Disease
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Ever been Medicated with Bisphosphonates
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Treated for Emotional Problems
Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
Please list the names and birthdates of any siblings:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
When sleeping, does your child...
...snore more than half the time?
...always snore?
...snore loudly?
...have "heavy" or loud breathing?
...have trouble breathing or struggle to breathe?
Have you ever seen your child stop breathing during the night?
Does your child...
...tend to breathe through the mouth during the day?
...have a dry mouth on waking up in the morning?
...occasionally wet the bed?
Does your child...
...wake up feeling un-refreshed in the morning?
...have a problem with sleepiness during the day?
Has a teacher or other supervisor commented that your child appears sleepy during the day?
Is it hard to wake your child up in the morning?
Does your child wake up with headaches in the morning?
Did your child stop stop growing at a normal rate at any time since birth?
Is your child overweight?
This child often does not seem to listen when spoken to directly.
This child often has difficulty organizing tasks and activities.
This child is often easily distracted by extraneous stimuli.
This child often fidgets with hands or feet or squirms in seat.
This child is often "on the go" or often acts as if "driven by a motor".
This child often interrupts or intrudes on others (e.g. butts into conversations or games)
Have your child's tonsils or adenoids been removed?
And if so, when?
To the best of my knowledge all above information is correct and it is my responsibility to inform the office of any changes in medical history. I also authorize the dental staff to perform the necessary orthodontic services. If Airway History is filled out, I consent to the collection of my child's breathing data along with photos and full orthodontic records for use in scientific research and analysis. If so, please submit below. Thank you.