Patient Biographical Information
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First Name:
*
Middle Initial:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Preferred email address for appointment confirmation:
Please list the names of any friends or family who we have seen before:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Information
Name of Person Responsible:
Parent's Marital Status:
Married
Partnered
Divorced
Separated
Widowed
Remarried
Single
Relationship to Patient:
Father
Mother
Grandparent
Guardian
Parents
Self
Spouse
Step Mother
Step Father
Other
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First Name:
*
Middle Initial:
*
Last Name:
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
Years at Address:
Birthdate:
Social Security #:
*
Home Phone:
Work Phone #:
Cell Phone:
Email:
Employer:
Length of Employment:
Relationship to Patient:
Father
Mother
Grandparent
Guardian
Parents
Self
Spouse
Step Mother
Step Father
Other
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Years at Address:
Birthdate:
Social Security #:
Home Phone:
Work Phone #:
Cell Phone:
Email:
Employer:
Length of Employment:
Insurance Information
Dental Insurance Company:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Phone #:
Policy Owner Name:
Relationship to Patient:
Father
Mother
Grandparent
Guardian
Parents
Self
Spouse
Step Mother
Step Father
Other
Policy Owner Birthdate:
Group #:
Insurance ID #:
Employer:
Dental Insurance Company:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Phone #:
Policy Owner Name:
Relationship to Patient
Father
Mother
Grandparent
Guardian
Parents
Self
Spouse
Step Mother
Step Father
Other
Policy Owner Birthdate:
Group #:
Insurance ID #:
Employer
Dental Insurance Co.
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Phone #:
Policy Owner Name:
Relationship to Patient
Father
Mother
Grandparent
Guardian
Parents
Self
Spouse
Step Mother
Step Father
Other
Policy Owner Birthdate:
Group #
Insurance ID #:
Employer
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
With who?
What is the patient's 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.
*
Requires antibiotic premedication before dental appointment?
No
Yes
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Speech problems/therapy?
No
Yes
*
Grind or clench teeth?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Pain, tenderness or noise in either jaw?
No
Yes
*
Frequent headaches?
No
Yes
*
Frequently Chew Gum?
No
Yes
*
Mouth breathing?
No
Yes
*
Snores during sleep?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
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.
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Require Antibiotic Premedication
No
Yes
*
Artificial Joints
No
Yes
*
Latex/Metal Allergy
No
Yes
*
Other Allergies
No
Yes
*
Heart Trouble
No
Yes
*
Rheumatic Fever
No
Yes
*
Prolonged Bleeding
No
Yes
*
Anemia
No
Yes
*
Lung Disease/Tuberculosis
No
Yes
*
Kidney Disease
No
Yes
*
Liver Disease
No
Yes
*
Hepatitis
No
Yes
*
Immune Problems
No
Yes
*
HIV/AIDS
No
Yes
*
Tumors or Growths
No
Yes
*
Endocrine Problems
No
Yes
*
Diabetes
No
Yes
*
Growth Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Arthritis
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Hearing or Vision Impairment
No
Yes
*
Tobacco Use
No
Yes
*
Women: Are you pregnant?
No
Yes
*
Ever Been Hospitalized
No
Yes
*
Surgeries
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
*
Other Condition Not Listed
No
Yes
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:
School:
Grade:
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
I understand the information that I have given is correct to the best of my knowledge and it is my responsibility to inform this office of any changes in the patient's medical status.
*
Name: