Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate (mm/dd/yyyy):    
*Gender:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Social Security #:
Whom may we thank for referring you to our clinic?
  Financial Party Information   
 
*First Name:  
Middle Initial:
*Last Name:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
  Dental Insurance Information    
Primary Dental Insurance
Subscriber's Name(Last, First, Middle):
Insurance Company:
   
DOB (mm/dd/yyyy):
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Dental Insurance
Subscriber Name(Last, First, Middle):
Insurance Company:
   
DOB (mm/dd/yyyy):
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Relationship to Patient:
 
  Dental History     
Dentist Name:
Dentist's Address:
Dentist's City:
Dentist State:
Dentist's Zip:
Dentist Phone Number:
Check-up Frequency:
Last Dental Visit (mm/dd/yyyy):  
Reason for last dental visit?
Has the patient had an orthodontic consultation?
If so, when (mm/dd/yyyy)?
Is the patient interested in orthodontic treatment?
Other dental specialists currently being seen?
Has the patient had any previous orthodontic treatment?
Has any member of the family been treated in this clinic?
Who suggested that you might need orthodontic treatment?
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?
  Bleeding of the gums?
  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?
  Treatment for TMJ problems?
If any of the above dental questions were answered 'Yes', please explain:
List any sports, hobbies, or musical instruments played:
   TMJ Questions     
  Do you experience any problems on opening your jaws when speaking, eating or yawning?   If you want, can you get your jaw out of joint?
  Do you experience any problems opening your jaws as far as you can?   Do you have pain in front of your ear?
  Do you grind your teeth at night, or during the day?   Do you clench your jaws?
  If you become tense do you grind your teeth?   Does your jaw ever click
  Do you have any clicking of the jaw joint in front of your ear?    Have you ever had an injury to your jaw?
  Do your jaw muscles ever get tired, or ache?   Other Problems related to your jaw joint?
If any of the above TMJ questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Physician's Phone Number:
Date of last Physical (mm/dd/yyyy):  
Patient Health:
Other physicians currently being seen and reason:
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
  Smoke or Chew Tobacco
  Mental Health Problems
  Osteoporosis
  Skin Disorders
  Sexually Transmitted Disease
  Pregnancy
  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
  Immune System Disorders
  Eating Disorders
  Vision, Hearing, or Speech Problems
  Birth Defects
  Broken Bones
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:
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:

Submitting this form constitutes your agreement to the following:  

I authorize release of any information regarding your or your child's orthodontic treatment to your dental and/or medical insurance company.

 

I have read the above questions and understand them.  I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form.  I will notify my orthodontist of any changes in my or my child's medical or dental health.