Confidential Patient Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Social Security #:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?   
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?
  Confidential Financial Party Information    
 
*First Name:  
Middle Initial:
*Last Name:  
Marital Status:
How long at this address?
*Main Phone:  
2nd/Cell Phone:
Email:
*Birthdate:  
Relationship to Patient:
*Address:  
*City:  
*State:  
*Zip:  
Previous Address (less than 3 years)
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
 
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Employer:
Occupation:
Birthdate:
Length of Employment:
Work Phone #:
Relationship to Patient:
  Dental Insurance Information    
Primary Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?   (If yes, complete information below)
Secondary Insurance
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
  Emergency Information    
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
  Dental History     
Dentist Name:
Check-up Frequency:   
Last Dental Visit:  
Has the patient had an orthodontic consult or treatment?
If so, when?

What is the patient's main orthodontic concern?
  Does the Patient need to premedicate prior to dental visit?    
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?
  Clench or Grind 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?
  Chipped or injured permanent teeth?
  Teeth sensitive to hot or cold?
  Previous root canal therapy?
  Bad taste/mouth odor?
  Previous periodontal (gum) treatment?
  Abnormal swallowing (tongue thrust)?
  Teeth that irritate tongue, cheek, lip, etc?
  Numerous fillings?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Frequently Chew Gum?
  Thumb or finger habit as a child?
  Jaw Fractures, cysts, mouth infections?
  Bleeding gums?
  Other periodontal (gum) problems?
  Frequent canker sores or cold sores?
  Have wisdom teeth been removed?
  Problems with food trapped between teeth?
  Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
  Have you had a TMJ screening?   Do you experience soreness in the muscles of your face or around your ears?
  Do you have a history of jaw joint problems?   Do you notice clicking or popping in your jaw joint?
  Have you been treated for "TMJ"?  Other jaw joint noises?
  Do you clench your teeth?   Do you have difficulty chewing or opening your mouth?  
  Has your jaw ever locked? Ringing in the ears?
  Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Address:
City:
State:
Zip:
Date of Last Physical:
Patient Health:
Is the patient in good health?     
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?     
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?     
List any medications currently being taken by the patient and the reasons for their use (include non-prescription):
Allergies or drug reaction to:
  Latex   Penicillin or other antibiotics
  Sulfa drugs   Aspirin, Ibuprofen, Tylenol
  Local anesthetics   Codeine or other narcotics  
  Other:
List any drug allergies or sensitivities (not listed above) 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.
  Heart Murmur
  Damaged or artificial heart valves
  Congenital Heart Defect
  Heart Problems
  Rheumatic Fever
  Angina
  Liver Disease / Jaundice / Hepatitis
  Kidney Disease
  Heart Attack/Stroke
  Hemophilia
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Anemia / Blood disorder
  HIV/AIDS
  Tonsils/Adenoids Removed
  Handicaps/Disabilities
  Arthritis / Joint problems
  Large Tonsils
  Sinus trouble
  Bed wetting
  Bone fractures/trauma to face/jaw
  Prosthetic joints
  Chronic fatigue
  Diabetes
  Growth Problems
  Tuberculosis or Lung Disease
  Pneumonia
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Arteriosclerosis
  Thyroid / Endocrine Problems
  Stomach ulcer or hyperacidity
  Hormone Therapy
  Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Seizures / Epilepsy / Neurological Disease
  Treated for Emotional Problems
  Asthma
  Respiratory problems / Emphysema
  Herpes/Cold Sores
  Sleep Apnea Diagnosis
  Persistent swollen neck glands
  HIV infection
  Low blood pressure
  Persistant cough
  FEMALES: Are you pregnant
  Take or Taken Bisphosphonates (Fosamax, Boniva)
Date last taken?
If any of the above medical questions were answered 'Yes' , please explain:
  Patient Motivation for Orthodontic Treatment    
Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)
Teeth - If your teeth could be changed, how would you like them to change?
 
Face - If your facial appearance could be changed, what would you change?
Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.
 
 
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
What is patient's attitude toward treatment?    
Height:
Weight:
School:
Grade:
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:
Has either biological parent ever had orthodontic treatment:
Please list siblings treated in our office: