*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
School:
City:
Grade:
Sibling Name/Birthdate:
Sibling Name/Birthdate:
Sibling Name/Birthdate:
Patient Hobbies:
Other family members seen in our office:
Referred by:
In order to help prevent a duplication of records, has the patient ever been seen by another orthodontist?
If so, when and by whom?
Responsible Party 1:
*First Name:
Middle Initial:
*Last Name:
Primary Phone:
Alternative Phone:
Email Address:
*Address:
*City:
*Zip:
Employer:
Occupation:
Social Security #:
*Birthdate:
Relationship to Patient:
Responsible Party 2 (if applicable):
First Name:
Middle Initial:
Last Name:
Primary Phone:
Alternate Phone:
Home Phone:
Address:
City:
Zip:
Employer:
Occupation:
Email Address:
Social Security #:
Birthdate:
Relationship to Patient:
PRIMARY INSURANCE
Insured Member:
Social Security No.:
Birthdate:
Primary Insurance Company:
Phone:
Address:
City:
State:
Zip:
Insured's Employer:
Group No.:
SECONDARY INSURANCE
Insured Member:
Social Security #:
Birthdate:
Secondary Insurance Company:
Phone:
Address:
City:
State:
Zip:
Insured's Employer:
Group No.:
Primary Dentist:
City:
Phone:
Primary Concern?
Date of Last Cleaning:
Have there been any teeth removed?
Is there or has there been a concern about periodontal (gum and bone) problems?
Is there any UNUSUAL dental history?
If yes, please explain:
Have any teeth been bumped or injured?
If yes, please explain:
Does the patient have a tendency to gag easily?
Do any speech problems exist?
Has the patient HAD or PRESENTLY HAVE any of the following habits:
Thumb sucking
Lip biting
Grinding or clenching teeth
Finger sucking
Nail biting
Snoring
Tongue thrusting
Mouth breathing
Smoking/Tobacco Chewing
Other
If yes, when did the habit stop?
Is the patient frightened or anxious about orthodontic treatment?
Is the patient concerned about the appearance of his/her teeth?
What apsect of orthodontic treatment are you most concerned?
Patient's Physician:
City:
Phone:
Has the patient HAD or PRESENTLY HAVE any of the following:
Heart Trouble
Tumors
HIV/AIDS
Emotional Problems
Heart Murmur
Convulsions
Bleeding Disorders
Headaches
Artificial Heart Valve/Pacemaker
Epilepsy
Glaucoma
Cleft Lip or Palate
Mitral Valve Prolapse
Cancer
Glandular Disorders
Jaw Clicking/Popping
High/Low Blood Pressure
Sleep Apnea
Genetic Disorders
Jaw Stiffness/Locking
Rheumatic Fever
Sleep Disorders
Kidney Disorders
Jaw Soreness
Diabetes
Hepatitis
Breathing Disorders
Arthritis
Tuberculosis
Fainting/Dizziness
Other
Is the patient's general health good at this time?
Is the patient now under the care of a physician at this time?
If yes, please explain:
Is the patient taking any medication(s) at this time?
Name of medication(s):
Is the patient allergic to any medication(s)?
Name of Medication(s):
Does the patient have a latex allergy?
Does the patient have a metal allergy?
Has the patient had tonsils and/or adenoids removed?
Has the patient had a serious illness or been hospitalized?
If yes, please explain:
Has the patient ever been advised by their physician to take an antibiotic prior to any dental procedures?
If yes, antibiotic name and method:
Has the patient shown signs of increased growth recently?
Present growth rate:
Has the patient reached puberty?
Does the patient have a more than normal tendency toward having a cold, ear infection, or sore throat?
Has the patient ever had a severe head or facial injury?
If yes, please explain:
Has the patient ever taken any prescribed diet medication(s)?
Name of medication(s):
Does the patient have any disease, condition, or problems not listed?
If yes, please explain:
Please use the space below to provide any helpful information. Feel free to include any questions you may have: