Please fill out the entire form and click the SUBMIT button at the bottom of the page when you are done. By submitting this form, you acknowledge that you are the patient or parent/legal guardian of the patient.
Confidential Patient Information
*First Name:
*Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Age:
*Gender:
Male
Female
*Address:
*City:
*State:
*Zip:
*Main or Cell Phone:
Home Phone:
*Email:
How would you like your appointment reminder?
Email
Text
Both
*Who does the patient live with (please give names)?
Select
Self
Parents
Legal Guardian
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?
Responsible Party Information
Check the box if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
Email:
*Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Employer:
Occupation:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID or Social Security #:
Group No.:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Subscriber ID or Social Security #:
Group #:
Insurance Co. Phone No.:
Emergency Information
*Name of Emergency Contact:
Phone:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had previous orthodontic treatment?
No
Yes
What is the patient's main orthodontic concern?
*Are you happy with your smile?
No
Yes
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?
No
Yes
Clench or Grind Teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Neck/shoulder pain?
No
Yes
Frequent sore throats?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Previous root canal therapy?
No
Yes
Bad taste/mouth odor?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Teeth that irritate tongue, cheek, lip, etc?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
No
Yes
Thumb or finger habit as a child?
No
Yes
Jaw Fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Have wisdom teeth been removed?
No
Yes
Problems with food trapped between teeth?
No
Yes
Is there any dental work yet to be completed?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Does your bite feel uncomfortable or unusual?
No
Yes
If any of the above dental questions were answered 'Yes' , please explain:
Medical History
Physician Name:
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Does the Patient need to be pre-medicated prior to dental visits for heart condition or any other conditions?
No
Yes
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
Other:
No
Yes
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
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital Heart Defect
No
Yes
Heart Disease
No
Yes
Rheumatic Fever
No
Yes
Angina
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV/AIDS
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Mitral Valve Prolapse
No
Yes
Allergy/Hives/Hay Fever
No
Yes
Smoking
No
Yes
Substance abuse problem (past or present)
No
Yes
Bone fractures/trauma to face/jaw
No
Yes
Cleft Lip/Palate
No
Yes
Chronic fatigue
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Tuberculosis or Lung Disease
No
Yes
Pneumonia
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
ADHD
No
Yes
Thyroid / Endocrine Problems
No
Yes
Stomach ulcer or hyperacidity
No
Yes
Hormone Therapy
No
Yes
Metal or Nickel Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Nervousness
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
Sexually transmitted disease
No
Yes
Low blood pressure
No
Yes
Persistent cough
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If patient is under the age of 18, please answer the following questions:
Has patient begun puberty:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patient Certification
*I certify that I am the patient/parent/legal guardian. I certify that I have answered and completed the above questions to the best of my knowledge and satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there are any changes later to this dental or medical history, I will inform the practice. I authorize Dr. Khouri or designated staff to perform such diagnostic records deemed appropriate to make an initial diagnosis of dental needs.
*I am the patient/parent/guardian/legal representative of the patient listed above and there are no court orders in effect that prohibit me from signing and submitting this consent.