Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Likes to be called:
*Age:
*Gender:
M
F
*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
M
F
Age:
3
M
F
Age:
2
M
F
Age:
4
M
F
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?
Y
N
(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:
Y
N
Do you see a dentist on a regular basis? Last Dental Visit:
Y
N
Have you been evaluated or had orthodontic treatment before? Where?
Y
N
Do you like your smile?
Y
N
Has there been any injury to your mouth, face, teeth, or chin? Date:
Y
N
Are you aware of any missing teeth/extra permanent teeth? List:
Y
N
Have you had any teeth extracted? If so, why?
Y
N
Any habits?
Thumb
Finger
Lip
sucking or
Fingernail
Pencil
Lip
biting? To what age?
Y
N
Have you ever had any noise, pain, stiffness, or difficulty openning in the jaw joint (TMJ/TMD)?
Y
N
Have ever been treated for a jaw joint problem?
Y
N
Any difficulty chewing or swallowing?
Y
N
Are you aware of any clenching/grinding of your teeth during the day/night?
Y
N
Do you brush your teeth daily?
Y
N
Do you floss daily?
Do you generally breath through your
Nose
Mouth
?
Do you have allergies/hayfever?
Seasonal
Year Round
Y
N
Have your adenoids and/or tonsils been removed? Date:
Y
N
Are you in good health?
Y
N
Any changes in your health in the past year?
Y
N
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?
Y
N
Rheumatic Fever
Y
N
Tuberculosis/Lung Disease
Y
N
Pneumonia
Y
N
Liver Disease
Y
N
Kidney Disease
Y
N
Heart Attack/Stroke
Y
N
Heart Disease
Y
N
Congenital Heart Defect
Y
N
Heart Murmur
Y
N
Hemophilia
Y
N
Hypertension/High Blood Pressure
Y
N
Prolonged Bleeding/Transfusion
Y
N
Anemia
Y
N
HIV/AIDS
Y
N
Hepatitis
Y
N
Tonsils/Adenoids Removed
Y
N
Cancer
Y
N
Family History of Cancer
Y
N
Received Radiation Treatment
Y
N
Growth Problems
Y
N
Endocrine Problems
Y
N
Hormone Therapy
Y
N
Latex/Metal Allergy
Y
N
Nervous Disorders
Y
N
Bone Disorders/Bone Loss
Y
N
Diabetes
Y
N
Seizures/Epilepsy
Y
N
Handicaps/Disabilities
Y
N
Asthma
Y
N
Arthritis
Y
N
Treated for Emotional Problems
Y
N
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.