Patient Biographical Information   
*First Name:
Middle Initial:
*Last Name:
Likes to be called:
*Age:
*Gender:
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
*Main Phone:
2nd/Cell Phone:
Email:
Previous address (if less than 3 yrs):  
Employer:    Occupation:     # Yrs Employed  
Whom may we thank for referring you to our practice?
Spouse's Name (if applicable):  
Names and ages of any children:
1       Age:  3       Age: 
2       Age:  4       Age: 
  Alternative Billing Information  (If different from patient)
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
Relationship to patient:  
*Address:
*City:
*State:
*Zip:
*Home #:
Cell #:
Work #:
Length of Employment:
Employer:
Occupation:
  Dental Insurance Information   
Subscriber's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber's Employer:
Birthdate:
Do you have dual dental coverage?   (If yes, complete information below)
Subscriber's Name:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Subscriber's Employer:
Birthdate:
Medical/Dental History    
What is your main dental concern at this time?  
What would you like orthodontic treatment to accomplish?  
Patient's Dentist:
   Do you see a dentist on a regular basis? Last Dental Visit:  
  Have you been evaluated or had orthodontic treatment before? Where? 
  Do you like your smile?
   Has there been any injury to your mouth, face, teeth, or chin? Date:  
  Are you aware of any missing teeth/extra permanent teeth? List: 
   Have you had any teeth extracted? If so, why? 
   Any habits?   sucking or    biting? To what age?  
  Have you ever had any noise, pain, stiffness, or difficulty openning in the jaw joint (TMJ/TMD)?
   Have ever been treated for a jaw joint problem?    Any difficulty chewing or swallowing?
   Are you aware of any clenching/grinding of your teeth during the day/night?
   Do you brush your teeth daily?     Do you floss daily?
Do you generally breath through your ?  
Do you have allergies/hayfever?
   Have your adenoids and/or tonsils been removed? Date:  
  Are you in good health?        Any changes in your health in the past year?
   Are you under the care of a physician? For what reason?  
Physician Name:
Phone:
Last visit date:
Any medications (over-the-counter/prescription) currently being taken? Please list with their reason:
Please list all allergies (incuding drug allergies):
Have you ever had any of the following medical problems?
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/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
Explain 'yes' responses:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and I understand it is my responsibility to inform this office of any changes in my medical status. This office reserves the right to obtain a credit bureau report for the purpose of considering payment options.