Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Preferred Phone:
Home Phone:
Cell Phone:
* Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
* How did you hear about our practice?
* Emergency Contact:
* Emergency Contact's Phone:

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Address:
* City:
* State:
* Zip:
* Preferred Phone:
Main Phone:
Cell Phone:
Email:
Relationship to Patient:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
* Do you have insurance that covers orthodontics?
Insurance Company Name:
Subscriber Name:
Subscriber ID:
Subscriber Birthdate:
Group Number:
Do you have another insurance that covers orthodontics?
Insurance Company Name:
Subscriber Name:
Subscriber ID:
Birthdate:
Group Number:

Dental History

* Dentist Name:
Check-up Frequency:
* Last Dental Visit:

We require that all patients are established with a dentist and have been to their dentist within the past year for a dental exam and cleaning.

Has the patient had prior orthodontic treatment?
If so, when?
Has the patient had prior orthodontic consultation?
If so, when?
How many times per day does the patient brush their teeth?
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave 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?
* Frequent neck/shoulder pain?
* Frequent sore throats?
* Frequent cold/canker sores?
* History of periodontal treatment?
* Floss teeth daily?
* Fluoride treatments?
* Breathes through the mouth more often than the nose?
* Snores during sleep?
* Requires SBE Prophylaxis Premedication
* Any missing permanent teeth?
* Any extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
* Bleeding Gums?
* Previous Extractions?
* Root Canal Treatment?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
* Rheumatic Fever
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Congenital Heart Defect
* Heart Murmur
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils Removed
* Adenoids Removed
* Eating Disorder
* Fainting/Dizziness
* Current Tobacco Use
* History of Tobacco Use
* Daily Alcohol Use
* History of Alcohol Abuse
* Current Use of Drugs or Marijuana
* History of Drug or Marijuana Use
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex Allergy
* Metal Allergy
* Received the HPV vaccine
* Nervous Disorders/Anxiety/Depression
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Arthritis
* Treated for Emotional Problems
* Ever Been Hospitalized
* Autism
* ADD or ADHD
* Sleep Apnea
If any of the above medical questions were answered 'Yes' , please explain:
Please explain any other medical concerns or medical history that may impact orthodontic treatment.

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
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:
Authorization