Patient Biographical Information
Last Name: First Name: Date of Birth: (mm/dd/yyyy)   School:	MaleFemale Age: Grade:
List any sports, hobbies or musical instruments:
What is the reason for your visit?
Home Address: City: Province: AB BC MB NB NL NS NT NU ON PE QC SK YT	Postal Code: Home Phone: Email:
Mother: First Name: Last Name: Address same as patient Home Address: City: Province: AB BC MB NB NL NS NT NU ON PE QC SK YT	Postal Code: Home Phone: Cell Phone: Work Phone:
If mother has dental insurance, please provide:
Name of Insurance Company: Group/Policy/Plan Number:	Date of Birth:(mm/dd/yyyy) ID or Certificate Number:
Mother2: First Name: Last Name: Address same as patient Home Address: City: Province: AB BC MB NB NL NS NT NU ON PE QC SK YT	Postal Code: Home Phone: Cell Phone: Work Phone:
If Mother2 has dental insurance, please provide:
Name of Insurance Company: Group/Policy/Plan Number:	Date of Birth:(mm/dd/yyyy) ID or Certificate Number:
Father: First Name: Last Name: Address same as patient Home Address: City: Province: AB BC MB NB NL NS NT NU ON PE QC SK YT	Postal Code: Home Phone: Cell Phone: Work Phone:
If father has dental insurance, please provide:
Name of Insurance Company: Group/Policy/Plan Number:	Date of Birth:(mm/dd/yyyy) ID or Certificate Number:
Father2: First Name: Last Name: Address same as patient Home Address: City: Province: AB BC MB NB NL NS NT NU ON PE QC SK YT	Postal Code: Home Phone: Cell Phone: Work Phone:
If Father2 has dental insurance, please provide:
Name of Insurance Company: Group/Policy/Plan Number:	Date of Birth:(mm/dd/yyyy) ID or Certificate Number:
Person(s) Responsible for Account:
Family Dentist:   Family Physician:	Date of last visit:
Whom may we thank for referring you?
Medical History
YesNo   Is your child in good health?  YesNo   Has your child had any serious illnesses/hospitaliztions?
Does your child currently have or have they been treated for any of the following: Rheumatic Fever HIV/AIDS Liver Disease ADD/ADHD Heart Murmur Hepatitis A, B or C Asthma Autism Mitral Valve Prolapse S.T.D. Arthritis Nervous Disorders Heart Disease Blood Diseases Bone Disorders Fainting or Dizziness Artificial Heart Valve Prolonged Bleeding Endocrine Problems Frequent Headaches Artificial Joints Diabetes Emotional Problems Epilepsy Tuberculosis Kidney Disorder Anxiety Other (please specify below)
If you checked any of the above, please give details:
List any medications now being taken:
List any drug allergies or sensitivities:
Have the tonsils or adenoids been removed? At what age?
Has the patient reached puberty? YesNo	Girls: Has menstruation started? YesNo Boys: Has voice changed yet? YesNo
Dental History
YesNo Has your child ever had any injuries to the face, mouth or teeth?  YesNo Has your child ever been treated for a jaw joint problem, including surgery?  YesNo Has your child ever sucked his/her thumb or finger? Until what age?  YesNo Does your child have any speech problems?  YesNo Does your child have any habit (nail biting, lip biting)?  YesNo Does your child have frequent canker or cold sores?  YesNo Is your child a mouth breather? While asleep? While awake?  YesNo Have you been informed of any missing or extra permanent teeth?  YesNo Has your child ever had a previous orthodontic examination?  YesNo Is your child apprehensive towards dental visits?  YesNo Does your child want orthodontic treatment?  YesNo Have any other family members had braces or orthodontic treatment?  How often does your child brush his/her teeth?  How often does he/she floss?
I hereby give Dr. Nicholas Karaiskos, and/or members of his team, permission to release information concerning my child's 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 child's 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 child's medical or dental history. I have read and understand this paragraph, and I authorize Dr. Nicholas Karaiskos to perform a complete orthodontic evaluation on my child.