Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
I prefer to be called:
*Birthdate:
Age:
*Gender:
Male
Female
Race:
*Address:
*City:
*State:
*Zip:
Phone:
School:
General Dentist:
Physician Name:
Other family members seen here:
No
Yes
How did you hear about our practice?
Dentist
Friend
Other
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
No
Yes
Does Patient have Orthodontic Insurance Coverage?
Primary Insurance Co. Name:
Policy Holder's Name:
TennCare
Policy Holder's DOB:
SS #:
Relationship to patient:
No
Yes
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?
No
Yes
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
No
Yes
Has menstruation begun?
Are you pregnant?
No
Yes
Have you ever had any of the following diseases or problems:
No
Yes
Abnormal Bleeding
No
Yes
ADD/ADHD
No
Yes
Adenoids/Tonsils Removed
No
Yes
Anemia
No
Yes
Artificial Bones/Joints/Valves
No
Yes
Asthma/Arthritis
No
Yes
Blood Transfusion
No
Yes
Cancer/Chemotherapy
No
Yes
Congenital Heart Defect
No
Yes
Diabetes
No
Yes
Difficulty Breathing
No
Yes
Drug/Alcohol Abuse
No
Yes
Emphysema
No
Yes
Epilepsy/Seizures/Fainting
No
Yes
Fever Blisters/Herpes
No
Yes
Glaucoma
No
Yes
Heart Attack/Stroke
No
Yes
Heart Murmur
No
Yes
Heart Surgery/Pacemaker
Hemophilia
No
Yes
Hepatitis
No
Yes
High/Low Blood Pressure
No
Yes
HIV+/AIDS
No
Yes
Hospitalization
No
Yes
Kidney Problems
No
Yes
Mitral Valve Prolapse
No
Yes
Osteoporosis/Bone Disorder
No
Yes
Pyschiatric Problems
No
Yes
Received Radiation Treatment
No
Yes
Rheumatic/Scarlet Fever
No
Yes
Severe/Frequent Headaches
No
Yes
Shingles
No
Yes
Sickle Cell Disease/Traits
No
Yes
Sinus Problems/Allergies
No
Yes
Syndromes
No
Yes
Tuberculosis
No
Yes
Ulcers/Colitis
No
Yes
Venereal Disease
No
Yes
Other
No
Yes
If any of the above questions were answered 'Yes', please explain:
Are you allergic to any of the following:
No
Yes
Aspirin
No
Yes
Any Metals/Plastics/Acrylics
No
Yes
Dental Anesthetics
Latex
No
Yes
Penicillin
No
Yes
Other:
No
Yes
Have you ever had or been evaluated for orthodontic treatment?
No
Yes
Have you ever had a serious/difficult problem associated with previous dental work?
No
Yes
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
No
Yes
Do you generally breathe through your mouth while awake?
No
Yes
Do you generally breathe through your mouth while asleep?
No
Yes
Do you like your smile?
Do you brush/floss daily?
No
Yes
Do your gums ever bleed?
No
Yes
Have you ever had an injury to your mouth?
No
Yes
Have you ever had an injury to your teeth?
No
Yes
Have you ever had an injury to your chin?
No
Yes
Do you smoke or use tobacco?
No
Yes
Do you have any missing or extra permanent teeth?
No
Yes
No
Yes
Lip Sucking/Biting
No
Yes
Tongue Thrusting
No
Yes
Thumb/Finger Sucking
Nail Biting
No
Yes
Speech Problems
No
Yes
Clenching/Grinding Teeth
No
Yes