Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Preferred Name:
*Birthdate:    
*Gender:  
Age:
Marital Status:
*Address:  
*City:  
*State:  
*Zip:  
*Main Phone:  
2nd/Cell Phone:
Email:
Occupation:
Employer:
Work #:
Dentist:
City:
Phone:
Spouse's Name: Occupation (spouse):
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?
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Please list the names of any siblings that have had treatment in our practice:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Employer:
Employer:
Occupation:
Occupation:
Father address (if different):
Mother's address (if different):
Work #:
Work #:
Father Cell #:
Mother Cell #
Father's date of birth:
  Mother's date of birth:
 
Parent's marital Status:
Parents' e-mail address(s):
 
  Dental History     
Dentist Name:
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?
  Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
City:
Phone:
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
  Artificial joints
  Glaucoma
  Cancer
  Bronchitis
  Received Radiation Treatment
  Currently under physician care
  Endocrine Problems (thyroid)
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Diabetes
  Seizures/Epilepsy
  Recent cold / flu
  Asthma
  Arthritis
  Treated for Emotional Problems
  Ever Been Hospitalized
  Emphysema
  Jaundice
If any of the above medical questions were answered 'Yes' , please explain:
  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:
Subscriber Name:
Subscriber Social Security #:
Subscriber Date of Birth:  
Subscriber ID#:
Subscriber Group #:
Employer:
Occupation:
Work Phone #:
   
Is there a Secondary Ins?
If so, please name the Insurance Company:
Subscriber Name:
Subscriber Social Security #:
Subscriber Date of Birth:  
Subscriber ID#:
Subscriber Group #: