Patient Biographical Information
Last Name:
First Name:  
Date of Birth:(mm/dd/yyyy)
Age:
Occupation:
Home Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone:
Email:
Work Phone:
Person Responsible for Account:  
Do you have dental insurance?  
If yes, please provide: Policy Holder's Name:  
Name of Insurance Company:
Group/Policy/Plan Number:
Policy Holder's Date of Birth (mm/dd/yyyy):
ID or Certificate Number:
Are you covered by any other dental insurance?  
If yes, please provide: Policy Holder's Name: 
Name of Insurance Company:
Group/Policy/Plan Number:
Policy Holder's Date of Birth:(mm/dd/yyyy)
ID or Certificate Number:
Family Dentist:
Family Physician:
Date of last visit:
Whom may we thank for referring you?  
What is the reason for your visit?  
Medical History
  Are you in good health? 
  Have you had any serious illnesses/hospitaliztions? 
Do you currently have or have you been treated for any of the following:
If you checked any of the above, please give details: 
List any medications now being taken: 
List any drug allergies or sensitivities: 
Do you smoke or chew tobacco? How often? 
WOMEN: Are you pregnant?  
Dental History
Have you ever had any injuries to the face, mouth or teeth? 
Have you ever been treated for a jaw joint problem, including surgery? 
Have you ever sucked your thumb or finger? Until what age? 
Do you have any speech problems? 
Do you have any habits (nail biting, lip biting)? 
Do you have frequent canker or cold sores? 
Are you a mouth breather? While asleep? While awake? 
Have you been informed of any missing or extra permanent teeth? 
Do you grind or clench your teeth? 
Do you have difficulty opening and/or closing your jaw? 
Have you ever had a previous orthodontic examination? 
Are you apprehensive towards dental visits? 
Have any other family members had braces or orthodontic treatment? 
How often do you brush your teeth? 
How often do you floss? 
I hereby give Dr. Nicholas Karaiskos, and/or members of his team, permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or other specialist as is deemed necessary from time to time. Such information includes radiographs (x-rays) and other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress. I also understand that my diagnostic records may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. I have read and understand this paragraph, and I authorize Dr. Nicholas Karaiskos to perform a complete orthodontic evaluation on me.