Patient Biographical Information   
*First Name:
Middle Initial:
*Last Name:
Likes to be called:
*Birthdate:  
*Gender:
Is patient adopted? At what age?  
*Address:
*City:
*State:
*Zip:
*Home #:
School:
Grade:
Hobbies/Sports Activities:
Please list the names and ages of other children in family:
1       Age:  4       Age: 
2       Age:  5       Age: 
3       Age:  6       Age: 
Whom may we thank for referring you to our practice?   Dentist:  
Person accompanying patient:   Relationship:  
Do you have custody of this child?  
  Responsible Party Information  
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:
Work Phone #:
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
Cell #:
Email:
Employer:
Occupation:
Length of Employment:
Work #:
  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:
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:
  Medical/Dental History    
What is the main orthodontic concern at this time?  
What would you like orthodontic treatment to accomplish?  
Child's attitude toward orthodontic treatment:  
  Does your child see a dentist on a regular basis? Last Dental Visit:  
  Has your child been evaluated or had orthodontic treatment before? Where? 
  Has there been any injury to the mouth, face, teeth, or chin? Date:  
  Are you aware of any missing teeth/extra permanent teeth? List: 
  Has your child had any teeth extracted? If so, why? 
  Any habits?   sucking or    biting? To what age?  
  Has your child ever had any noise, pain, stiffness, or difficulty openning in the jaw joint (TMJ/TMD)?
  Has your child ever been treated for a jaw joint problem?    Any difficulty chewing or swallowing?
  Are you aware of any clenching/grinding of your child's teeth during the day/night?
  Does your child brush their teeth daily?     Does your child floss daily?
Does your child generally breath through their ?  
Does your child have allergies/hayfever?
  Have the adenoids and/or tonsils been removed? Date:  
  Is your child in good health?       Any changes in your child's health in the past year?
Physician Name:
Phone:
Last Visit Date:
Any medications (over-the-counter/prescription) currently being taken? Please list with reason:
Please list all allergies (including drug allergies):
Has patient begun puberty?
If patient is a girl, has menstruation begun:
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/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 answers:
Other disease, condition, serious illness or problem not listed here we should know about?
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 child's medical status. This office reserves the right to obtain a credit bureau report for the purpose of considering payment options.