ORTHODONTIC PATIENT INFORMATION AND HEALTH HISORY
First Name: 
Last Name:
Birthdate: 
Gender: 
Address: 
City: 
State: 
Zip: 
Home Phone: 
School: 
Cell Phone: 
Grade: 
Hobbies/Sports:             
Whom may we thank for this referral? 
Have any other family members or siblings been to our practice? 
Email Address for billing and appointment confirmation: 
FAMILY (For Patients Under 18) 
Father's Name: 
Occupation: 
Mother's Name: 
Occupation: 
Relationship to patient: 
Employer: 
Relationship to patient: 
Employer: 
Parents' Marital Status:         
Patient Living with:   
PERSON RESPONSIBLE FOR FINANCIAL MATTERS
First Name:
Last Name:
Home Phone:
Cell Phone: 
Work Phone: 
Address: 
City: 
State: 
Zip: 
Employer: 
Occupation: 
PRIMARY INSURANCE INFORMATION 
Name of Insured: 
Insured Soc. Sec./ID #: 
Employer: 
Relationship to patient: 
Insured Birthdate: 
Insurance Company: 
Insurance Address: 
SECONDARY INSURANCE INFORMATION 
Name of insured: 
Insured Soc. Sec./ID #: 
Employer: 
Relationship to patient: 
Insured Birthdate: 
Insurance Company: 
Insurance Address: 
PATIENT'S DENTIST  PATIENT'S PHYSICIAN 
Name: 
Address: 
Phone: 
Name: 
Address: 
Phone: 
Has any other orthodontist been consulted regarding this patient? 
Has the patient had previous orthodontic treatment (please explain)?
MEDICAL HISTORY 
Please describe any major illnesses or hospitalizations:
Is the patient taking any medications? 
Has the patient been under the care of a physician during the past 3 years, other than for routine examination (please explain)?
Has the patient ever had (please check): 
Other (please describe):
LATEX ALLERGY: 
Does the patient have any other allergies (List)? 
Does the patient require premedication prior to dental treatment? 
Has the patient reached puberty (menstruation, voice change) yes or no? If yes, how long ago? 
DENTAL HISTORY 
Date of last dental visit:    Were the patient's teeth cleaned at this time? 
How often does the patient brush his/her teeth? 
Is there a history of trauma to any teeth? 
If so, please explain: 
Has the patient ever had or is there a history of: (please check) 
What is the patient's primary concern? What brings you to the office today?
What is expected from orthodontic treatment?
What is the patient's interest in treatment? 
Realizing that successful treatment greatly depends upon the patient’s complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?