Patient Biographical Information    
Please indicate whether the patient is an adult or a minor.
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
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?
If minor, which school does the patient attend?
  Responsible Party    
 
*First Name:  
Middle Initial:
*Last Name:  
Marital Status
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Relationship to Patient:
Social Security #:
Work Phone #:
  Additional Responsible Party Information (if applicable)    
First Name:
Middle Initial:
Last Name:
Marital Status
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Social Security #:
Work Phone #:
  Dental Insurance  
Subscriber Name: Insurance Company:
Relationship to patient Employer:
Subscriber Birthdate: Subscriber ID or SS#:
    Group Number:
Does your insurance cover orthodontics?
Do you have dual insurance?                   If yes, complete the following
Subscriber Name: Insurance Company:
Relationship to patient Employer:
Subscriber Birthdate Subscriber ID or SS#:
    Group Number:
Does your insurance cover orthodontics?
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultation 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?
 Autism or Autism Spectrum Disorder
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?
 ADHD/ADD
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
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
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:
  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:
Height:
Weight:
School:
Grade:
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: