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: NoYes 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
NoYes  Does Patient have Orthodontic Insurance Coverage? Primary Insurance Co. Name: Policy Holder's Name:	TennCare Policy Holder's DOB:   SS #: Relationship to patient:
NoYes  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? NoYes	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
NoYes Has menstruation begun?	Are you pregnant?  NoYes
Have you ever had any of the following diseases or problems:
NoYes  Abnormal Bleeding NoYes  ADD/ADHD NoYes  Adenoids/Tonsils Removed NoYes  Anemia NoYes  Artificial Bones/Joints/Valves NoYes  Asthma/Arthritis NoYes  Blood Transfusion NoYes  Cancer/Chemotherapy NoYes  Congenital Heart Defect NoYes  Diabetes NoYes  Difficulty Breathing NoYes  Drug/Alcohol Abuse NoYes  Emphysema NoYes  Epilepsy/Seizures/Fainting NoYes  Fever Blisters/Herpes NoYes  Glaucoma NoYes  Heart Attack/Stroke NoYes  Heart Murmur NoYes  Heart Surgery/Pacemaker	Hemophilia   NoYes Hepatitis   NoYes High/Low Blood Pressure   NoYes HIV+/AIDS   NoYes Hospitalization   NoYes Kidney Problems   NoYes Mitral Valve Prolapse   NoYes Osteoporosis/Bone Disorder   NoYes Pyschiatric Problems   NoYes Received Radiation Treatment   NoYes Rheumatic/Scarlet Fever   NoYes Severe/Frequent Headaches   NoYes Shingles   NoYes Sickle Cell Disease/Traits   NoYes Sinus Problems/Allergies   NoYes Syndromes   NoYes Tuberculosis   NoYes Ulcers/Colitis   NoYes Venereal Disease   NoYes Other   NoYes
If any of the above questions were answered 'Yes', please explain:

Are you allergic to any of the following: NoYes  Aspirin NoYes  Any Metals/Plastics/Acrylics NoYes  Dental Anesthetics	Latex NoYes Penicillin NoYes Other:
NoYes  Have you ever had or been evaluated for  orthodontic treatment? NoYes  Have you ever had a serious/difficult problem  associated with previous dental work? NoYes  Do you now or have you ever experienced  pain/discomfort in your jaw joint (TMJ/TMD)? NoYes  Do you generally breathe through your mouth  while awake? NoYes  Do you generally breathe through your mouth  while asleep? NoYes  Do you like your smile?	Do you brush/floss daily? NoYes Do your gums ever bleed? NoYes Have you ever had an injury to your mouth? NoYes Have you ever had an injury to your teeth? NoYes Have you ever had an injury to your chin? NoYes Do you smoke or use tobacco? NoYes Do you have any missing or extra permanent teeth? NoYes

NoYes Lip Sucking/Biting NoYes Tongue Thrusting NoYes Thumb/Finger Sucking Nail Biting NoYes Speech Problems NoYes Clenching/Grinding Teeth NoYes