Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
Age:
*Gender:  
If a minor: Who is accompanying your child today?
*Street Address:  
*City:  
*State:  
*Zip:  
Cell Phone:
Home Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
Whom may we thank for referring you to our practice?
Hobbies/Sports:
  Adult Patient    
 
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Phone:
Social Security #:
Employer:
Job Title:
  Responsible Party    
  Patients Under 18 Yrs Old    
Parents Marital Status:
Mother's Information     
Name:
Work #:
Employer:
Address:
   
Birthdate:
SS#:
Cell#:
Job Title:
Father's Information     
Name:
Work #:
Employer:
Address:
Birthdate:
SS#:
Cell#:
Job Title:
  Insurance Information    
Do you have insurance that covers orthodontics?
Primary Coverage
Insurance Co. Name:
Insurance Co. Address:
Group#:
Policy Owners Name:
Policy Owner's Birthdate:
If yes, please complete the following:
   
Tel #:
ID#:
   
Employer:
Relationship to Patient:
Secondary Coverage
Insurance Co. Name:
Insurance Co. Address:
Group#:
Policy Owners Name:
Policy Owner's Birthdate:
   
Tel #:
ID#:

   
Employer:
Relationship to Patient:
  Dental History     
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consultant or treatment?
If so, when?
What is the main concern you would like orthodontics to accomplish?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Informed of Any missing or extra permanent teeth?
  Speech problems?
  Tongue thrust?
  Grind or clench teeth?
  Lip sucking/biting?
  Thumb/Finger sucking?
  Nail biting?
  Mouth breathing?
  Injury to the face, jaws, teeth or mouth?
  Discomfort from teeth or gums?
  Pain, tenderness or noise in either jaw? (TMJ)
  Frequent headaches?
  Neck/shoulder pain?
  Frequent sore throats?
  Requires antibiotic prophylaxis prior to dental visits?
  Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Telephone #:
Date of last Physical:
Patient Health:
Please list any medications being taken by the patient:
Please list all drug allergies or sensitivities that the patient may have:
Any other allergies:
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
  Pneumonia
  Liver Disease
  Kidney Disease
  Ulcers/Colitis
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Mitrial Valve Prolapse
  Hemophilia
  Hypertension/High Blood Pressure
  Abnormal Bleeding/Transfusion
  Anemia
  Tonsils/Adenoids Removed
  Cancer
  Hepatitis
  For Women: Are you pregnant or nursing?
  Family History of Cancer
  Received Radiation or Chemotherapy
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Hearing Impairment
  Handicaps/Disabilities
  Asthma
  Arthritis
  Lupus
  ADD/ADHD
  Anxiety Disorder
  Ever Been Hospitalized
Have you ever taken or are you scheduled to begin taking a bisphosphonate medication (antiresorptive agent) such as Aredia, Zometa, XGEVA, Fosamax, Reclast, or other?    
If any of the above medical questions were answered 'Yes' , please explain:
Please list any other serious medical condition that you have had:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
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:
I understand that the information that I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes to the medical status.