Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Birthdate:    
*Gender:  
*Address:  
*City:  
*State:  
*Zip:  
*Cell Phone:  
*2nd/Home Phone:  
*Email:  
Social Security #:
Marital Status:  
School:
   
Grade:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Please list the names of any friends or family currently in the practice:
  Parental Information    
Mother's Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
2nd/Home Phone:
Email:
Father's Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Cell Phone:
2nd/Home Phone:
Email:
Person responsible for the Account:
  Dental Insurance Information    
Primary
Orthodontic Coverage:
Insured's Full Name:
I.D.:
Date of Birth:  
Employer Name:
Insurance Co. Name:
Insurance Co Address:
Group No.:
Secondary
Orthodontic Coverage:
Insured's Full Name:
I.D.:
Date of Birth:  
Employer Name:
Insurance Co. Name:
Insurance Co. Address:
Group No.:
  Emergency Contact Information    
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Cell Phone:
Relation:
2nd/Home Phone:
Address:
  Dental History     
Dentist Name:  
Phone No.:
Address:
Last Dental Visit:  
Last Panoramic
x-ray taken:
 
  Have you ever had extractions?
  Have you ever had periodontal treatment (gum treatment)?
Has the patient had an orthodontic evalutation or treatment?
If so, when?
   
   
   
    How long ago:  
Describe treatment:    
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.
  Locking of the jaw joint?
  Pain in jaw joint?
  Finger/thumb sucking habit?
  Snores during sleep?
  Were your "wisdom teeth" removed?
  Grind or clench teeth?
  Speech problems/therapy?
  Mouth breathing?
  Any missing or extra permanent teeth?
  Requires premedication?
If any of the above dental questions were answered 'Yes', please explain below:
   Medical History     
Physician Name:
Phone No.:
Date of last Physical:  
Patient Health:
List any medications currently being taken by the patient:
List any serious medical condition(s) you have/had:
Are you allergic or have any sensitivity to any of the following?
  Nickel/metal
  Latex
  Iodine
  Codeine
  Dental Anesthetics
  Sulfa Drugs
  Erythromycin
  Aspirin
  Tetracyline
  Penicillin
    Other:
Please share any information with us that you feel will be helpful for us to know in treating you:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Anemia
  Blood Transfusion
  Congenital Heart Defect
  Liver Disease
  Hepatitis
  Tuberculosis/Lung Disease
  Heart Attack/Stroke
  Fever Blisters/Herpes
  Pregnant
  Radiation Treatment
  Endocrine Problems
  HIV/AIDS
  Asthma
  Cancer
  Kidney Disease
  Pneumonia
  Seizures/Epilepsy
  Heart Murmur
  Drug/Alcohol Abuse
  Glaucoma
  Nursing
  Bone Loss
  Hormone Therapy
  Growth Problems
  Arthritis
  Chemotherapy
  Tonsils/Adenoids Removed
  Diabetes
  Hemophilia
  Hypertension/Low Blood Pressure
  Emphysema
  Mitral Valve Prolapse
  Handicaps/Disabilities
  Rheumatic Fever
  Psychiatric Problems
  Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain: