Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Mother/Guardian’s Name:
Father/Guardian’s Name
Please list the names of immediate family members that have been to this Practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Motivation for Seeking Treatment

Please help us to understand your concerns or desires by sharing the following information; please be specific.
General Concerns:
Teeth/Smile - Is there anything about your smile or teeth that you'd like to change?
Symptoms:

Dental Insurance Information

Policy Holder’s Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder’s Name:
Policy Holder’s Relationship:
Policy Holder DOB:
Do you have dual dental coverage? (If yes, complete information below)
Policy Holder’s Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder’s Name:
Policy Holder’s Relationship:
Policy Holder DOB:

Emergency Contact Information

Name:
Address:
City:
State:
Zip:
Phone:
Relationship to Patient:
In case of emergency, is it OK to release medical/dental information?

Dental History

Dentist Name:
Checkup Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment? If so, when?
Have your teeth changed in the last five years, become shorter, thinner, or worn? If yes, please explain:
Do you wear/have you ever worn a bite appliance?
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech concerns/therapy?
Snores during sleep?
Grind or clench teeth?
Diagnosis of Sleep Apnea?
Injury to face, jaw, teeth or mouth?
Wake up tired after a full night of sleep?
Neck/shoulder pain?
Pain, tenderness or noise in either jaw?
Discomfort from teeth or gums?
Prosthetic joints?
Artificial heart valves?
Requires premedication for dental visits?
Oral habits (thumb/finger sucking, lip/nail biting)?
Any missing or extra teeth?
Dry mouth (Sjogren's syndrome?
Frequent headaches?
Sensitive gagging reflex?
Mouth breathing?
If any of the above dental questions were answered 'Yes' or you have any other dental concerns, please explain?

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:
Please list any medications currently being taken by the patient (include non-prescription):
List any allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Growth Problems
Tuberculosis/Lung Disease
Endocrine/Thyroid Problems
Pneumonia
Hormone Therapy
History of smoking
Tonsils/Adenoids Remove
Liver Disease
Bone Disorder/Bone Loss
Heart Disease
Past or Present treatment for Osteoporosis/osteopenia (Fosamax)
Heart Attack/Stroke
Seizures/Epilepsy
Heart Murmur
Faints easily
Congenital Heart Defect
Inflamatory Rheumatism
Hypertension/High Blood Pressure
Arthritis
Hemophilia
Handicaps/Disabilities
Prolonged Bleeding/Transfusion
Asthma
Anemia
ADHD
Heptitis
Anxiety with new experiences
HIV/AIDS
Autism/autism spectrum disorder/Aspergers/PPD
Metal Allergy
Latex Allergy
Herpes (Oral cold sores)
Cancer
Received Radiation Treatment
If any of the above medical questions were answered 'Yes' , please explain:
List any surgeries:

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone:
By typing my name below, I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any error or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
Signature: