Potomac Falls, Va 20165 | Ashburn, Va 20148
Patient Biographical Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Gender:   Male Female
*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?

Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:   Middle Initial: *Last Name:	*Address:   *City:   *State:   *Zip:
*Main Phone:   2nd/Cell Phone: Email: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Do you have insurance that covers orthodontics? NoYes If so, please name the Insurance Company below:	Social Security #: Employer: Occupation: Length of Employment: Work Phone #:
Dental Insurance Information
First Name of Insured:     MI:   Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Employer:   Group #:   NoYes  Is patient covered by another dental plan? First Name of Insured:     MI:     Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Employer:   Group #:	Last:   Insured Birthdate:    Insurance Phone #:   Member/Subscriber ID#:   Carrier Name:   Last:   Insured Birthdate:    Insurance Phone #: Member/Subscriber ID#:

Dental History
Dentist Name: Check-up Frequency: Once per year Twice per year More than twice a year Never Emergencies only Last Dental Cleaning:	Has the patient had an orthodontic consultant or treatment? NoYes If so, when?
What is the patients main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
NoYes Speech problems/therapy?   NoYes Grind or clench teeth?   NoYes Oral habits (thumb/finger sucking, lip/nail biting)?   NoYes Injury to face, jaw, teeth or mouth?   NoYes Discomfort from teeth or gums?   NoYes Pain, tenderness or noise in either jaw?   NoYes Frequent headaches?   NoYes Neck/shoulder pain?   NoYes Frequent sore throats?	NoYes Brush teeth daily?   NoYes Floss teeth daily?   NoYes Fluoride treatments?   NoYes Mouth breathing?   NoYes Snores during sleep?   NoYes Requires premedication?   NoYes Any missing or extra permanent teeth?   NoYes Apprehensive about dental care?   NoYes Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History
Physician Name: Address: City: State: Zip:	Date of last Physical:   Patient Health: Good Excellent Fair Poor
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.
NoYes Rheumatic Fever   NoYes Tuberculosis/Lung Disease   NoYes Pneumonia   NoYes Liver Disease   NoYes Kidney Disease   NoYes Heart Attack/Stroke   NoYes Heart Disease   NoYes Congenital Heart Defect   NoYes Heart Murmur   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Prolonged Bleeding/Transfusion   NoYes Anemia   NoYes HIV/AIDS   NoYes Hepatitis   NoYes Tonsils/Adenoids Removed	NoYes Cancer   NoYes Family History of Cancer   NoYes Received Radiation Treatment   NoYes Growth Problems   NoYes Endocrine Problems   NoYes Hormone Therapy   NoYes Latex/Metal Allergy   NoYes Nervous Disorders   NoYes Bone Disorders/Bone Loss   NoYes Diabetes   NoYes Seizures/Epilepsy   NoYes Handicaps/Disabilities   NoYes Asthma   NoYes Arthritis   NoYes Treated for Emotional Problems   NoYes 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: Please list the name and birthdate of any siblings: Height: Weight: School: Grade: Father/Guardian 1 Name: Mother/Guardian 2 Name: Has patient begun puberty: NoYes If patient is a girl, has menstruation begun: NoYes If patient is a boy, has their voice changed or have facial hair: NoYes Has the patient grown in the past year or has their shoe size changed recently: NoYes Patient's interest in treatment: Patient wants treatment Patient unwilling, but agrees Treatment only if necessary Patient un-cooperative Has either biological parent ever had orthodontic treatment: Don't Know Yes No