Patient Biographical Information    
*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?
  Family Information (For Patients Under 18)    
Father's Information:
Name:
Home #:
Cell Phone:
Employer:
Work #:
Mother's Information:
Name:
Home #:
Cell Phone:
Employer:
Work #:
Parents Marital Status:               
Siblings:
Name:
Name:
Name:
Birthdate:  
Birthdate:  
Birthdate:  
Person Responsible for the Account:            Name: 
Address:
Email:
Home Phone:
Work Phone:
Cell Phone:
  Dental Insurance    
Primary Insurance Co.:
Phone #:
Insured Name:
Birthdate:  
Employer:
SS/ID#:
Group #:
Secondary Insurance Co.:
Phone #:
Insured Name:
Birthdate:  
Employer:
SS/ID#:
Group #:
  Dental History     
Dentist Name:
Dentist Address:
Dentist Phone:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultant 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?
  Mouth breathing?
  Snores during sleep?
  Requires premedication?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Periodontal disease?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
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
  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
  Have you ever taken any bisphosphonates medications?
  Cancer
  Medication Allergy
  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:
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:
Individual Completing Form:
Relationship to Patient: