Patient Biographical Information    
*First Name:
Middle Initial:
*Last Name:
I prefer to be called:
*Birthdate:  
Age:
*Gender:
Race:
*Address:
*City:
*State:
*Zip:
Phone:
School:
General Dentist:
Physician Name:
Other family members seen here:
How did you hear about our practice?
  Legal Guardian Information   
Please list those with legal custody of patient:
Name:
Relationship to Patient:
Address:
Email:
Home #:
Cell #:
Employer:
Work #:
Identifying factor: (Birthday or social security number) 
Name:
Relationship to Patient:
Address:
Email:
Home #:
Cell #:
Employer:
Work #:
Identifying factor: (Birthday or social security number) 
  Insurance Information   
 Does Patient have Orthodontic Insurance Coverage?
Primary Insurance Co. Name:
Policy Holder's Name:
Policy Holder's DOB:  
SS #:
Relationship to patient:
 Does Patient have Secondary Insurance Coverage?
Secondary Insurance Co.:
Policy Holder's Name:
Policy Holder's DOB:  
SS #:
Relationship to Patient:
Work #:
  Medical History
Are you taking any prescription/over the counter medications?
If yes, please list:
What are the main concerns that you would like orthodontics to accomplish?
Please list any serious medical conditions, past or present:
  For Girls     
Has menstruation begun?
Are you pregnant?  
Have you ever had any of the following diseases or problems:
 Abnormal Bleeding
 ADD/ADHD
 Adenoids/Tonsils Removed
 Anemia
 Artificial Bones/Joints/Valves
 Asthma/Arthritis
 Blood Transfusion
 Cancer/Chemotherapy
 Congenital Heart Defect
 Diabetes
 Difficulty Breathing
 Drug/Alcohol Abuse
 Emphysema
 Epilepsy/Seizures/Fainting
 Fever Blisters/Herpes
 Glaucoma
 Heart Attack/Stroke
 Heart Murmur
 Heart Surgery/Pacemaker
Hemophilia  
Hepatitis  
High/Low Blood Pressure  
HIV+/AIDS  
Hospitalization  
Kidney Problems  
Mitral Valve Prolapse  
Osteoporosis/Bone Disorder  
Pyschiatric Problems  
Received Radiation Treatment  
Rheumatic/Scarlet Fever  
Severe/Frequent Headaches  
Shingles  
Sickle Cell Disease/Traits  
Sinus Problems/Allergies  
Syndromes  
Tuberculosis  
Ulcers/Colitis  
Venereal Disease  
Other  
If any of the above questions were answered 'Yes', please explain:
Are you allergic to any of the following:
 Aspirin
 Any Metals/Plastics/Acrylics
 Dental Anesthetics
   
Latex
Penicillin
Other:
 Have you ever had or been evaluated for  orthodontic treatment?
 Have you ever had a serious/difficult problem  associated with previous dental work?
 Do you now or have you ever experienced  pain/discomfort in your jaw joint (TMJ/TMD)?
 Do you generally breathe through your mouth  while awake?
 Do you generally breathe through your mouth  while asleep?
 Do you like your smile?
Do you brush/floss daily?
Do your gums ever bleed?
Have you ever had an injury to your mouth?
Have you ever had an injury to your teeth?
Have you ever had an injury to your chin?
Do you smoke or use tobacco?
Do you have any missing or extra permanent teeth?
Lip Sucking/Biting
Tongue Thrusting
Thumb/Finger Sucking
Nail Biting
Speech Problems
Clenching/Grinding Teeth