PATIENT INFORMATION
*Last Name                         *First Name                      MI    Preferred
*Birthdate:
*Sex:
Street:                                City:                                 State:    Zip:
Home Phone: 
 Cell Phone:     
If Patient is a minor, name of person(s) with patient at exam: Relationship to patient: 
Have we previously treated any other family member?  If yes, whom? 
What is expected from orthodontic treatment? 
Patient's attitude toward braces 
Whom may we thank for this referral? 
How did you learn about our orthodontic office?
       
    
     
ACCOUNT INFORMATION
If Patient is a Minor:
Custodial Parent/Legal Guardian # 1 (Last, First, MI):                               Relationship to patient:
     

Street:                               City:                                 State:    Zip:                                          Daytime Phone/Cell:
       
Do you rent or own?    Employer:      E-Mail address: 
How long have you been at this address?     Marital status: 
 
Custodial Parent/Legal Guardian # 2 (Last, First, MI):                                Relationship to patient:
      

Street:                               City:                                 State:     Zip:                                         Daytime Phone/Cell:
       
Do you rent or own?   Employer:       E-Mail Address: 
If Patient is an Adult:
Employer  Occupation: 
DaytimePhone/Cell:  E-Mail Address: 
INSURANCE   
Name of Dental Insurance Company: 
Street:                               City:                                  State:                               Zip:
Name of Subscriber:  Subscriber's Date of Birth:
ID# or Social Security #:  Insurance Company Phone Number: 
EMERGENCY CONTACT (person not living with patient)
Name:  Relationship to Patient: 
Address:  Home Phone: 
City:     State:     Zip:    Work Phone: 
MEDICAL / DENTAL HISTORY
Family Dentist:    Address:    Date of last dental visit: 
Is the patient under a physician's care?    If yes, for what? 
List any medications now being taken:    For what reason? 
List allergies to any medications: 
Approximately how much has the patient grown in the last year? 
Mother's Height:                                  Father's Height: 
Has the patient reached puberty?
(Boys: voice changing, Girls: menstruating)
 
Has the patient been diagnosed or treated for any of the following? (Check all that apply)
         
             
       
Does the patient require medication before dental visits? 
Does the patient have a latex allergy? 
Does patient have a persistent thumb or finger habit?       Until Age? 
Is the patient a mouth breather?   
Does the patient vomit, gag, or faint easily? 
Does the patient experience headaches or neck aches, especially under stress? 
Does the patient clench or grind the teeth? 
Has the patient had any injuries involving the jaw or teeth? 
Has the patient experienced any pain, popping, or locking of the jaw? 
Has the patient ever been evaluated regarding a jaw problem? 
Has the patient ever been treated for periodontal disease or has treatment been recommended? 
Is patient missing any permanent teeth? 
Does patient have any extra permanent teeth? 
Has patient had any teeth removed by extraction? 
Does the patient have a history of major illness?
Have tonsils and/or adenoids been removed?
Has the patient had any major operations?
Has the patient been involved in a serious accident?
Do the patient's gums bleed when brushed?
Has the patient ever had any speech problems/speech therapy?
Are there any problems, handicaps, or restrictions that may have a bearing on successful orthodontic treatment?
FEMALES: Are you pregnant or trying to become pregnant?
FEMALES: Has menstruation started? If so, at what age?  
Is patient adopted? At what age? 
Is patient/parent aware that appointments will infringe on work/school?