Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
*Cell Phone:  
2nd Phone:
Social Security #:
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?
  Financial Party Information    
*First Name:  
Middle Initial:
*Last Name:  
*Years at current address:  
*Cell Phone:  
2nd Phone:
Relationship to Patient:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Social Security #:
*Source of Income:  
*How long have you been at the current employer?  
Length of Employment:
Work Phone #:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultant or treatment?
If so, when?
What is the patients main orthodontic concern?
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?
  Grind or clench teeth?
  Oral habits (thumb/finger sucking, lip/nail biting)?
  Injury to face, jaw, teeth or mouth?
  Discomfort from teeth or gums?
  Pain, tenderness or noise in either jaw?
  Frequent headaches?
  Neck/shoulder pain?
  Frequent sore throats?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Requires premedication?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Date of last Physical:  
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities 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.
  Rheumatic Fever
  Tuberculosis/Lung Disease
  Liver Disease
  Kidney Disease
  Heart Attack/Stroke
  Heart Disease
  Congenital Heart Defect
  Heart Murmur
  Hypertension/High Blood Pressure
  Prolonged Bleeding/Transfusion
  Tonsils/Adenoids Removed
  Family History of Cancer
  Received Radiation Treatment
  Growth Problems
  Endocrine Problems
  Hormone Therapy
  Latex/Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Treated for Emotional Problems
  Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

  By typing in my initials in the box here, I attest that I have read and understand the above questions and the information provided is accurate to my knowledge. I also acknowledge that neither the orthodontist nor any member of her staff is responsible for any errors or omissions I made in the completion of this form. I agree to inform the practice of any changes to this history and/or the patient’s medical/dental status.