Welcome to our practice! Please take a few minutes to provide us with the following important information.
Confidential Patient Information
First Name:
Middle Name:
Last Name:
Preferred Name:
Gender:
Male
Female
Non-Binary
Transgender Male
Transgender Female
Other
Prefer Not to Answer
Pronouns:
He/Him
She/Her
They/Them
Other
Date of Birth:
Street Address:
City:
Province:
Postal Code:
Patient's Phone Number (if applicable):
Patient's Email (if applicable):
How did you hear about our practice?
School and Grade:
Are there any siblings or family members who are patients at our office?
Does the patient play any sports, hobbies or musical instruments?
Family Information
The following information is requested so that we can communicate properly with the people involved with treatment.
Parent/Guardian #1:
Relationship to patient:
First Name:
Last Name:
Check if same as above.
Street Address:
City:
Province:
Postal Code:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email:
Parent/Guardian #2:
Relationship to patient:
First Name:
Last Name:
Check if same as above.
Street Address:
City:
Province:
Postal Code:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
Email:
Other Family Information:
Are there any other responsible adults/guardians we should know about?
First Name:
Last Name:
Relationship:
Phone Number:
Who is the emergency contact?
Are there any other family members who are interested in orthodontic treatment?
Insurance Information
Primary Insurance Plan:
Do you have insurance that may cover orthodontic treatment?
Yes
No
Not Sure
Policyholder Name:
Relationship to Patient:
Policyholder Date of Birth:
Employer:
Insurance Company:
Group/Policy #:
Subscriber/Member ID:
Secondary Insurance Plan:
Policyholder Name:
Relationship to Patient:
Policyholder Date of Birth:
Employer:
Insurance Company:
Group/Policy #:
Subscriber/Member ID:
Medical Information
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
General Practitioner Name:
Has the patient had any major illnesses, operations or hospitalizations in the last 5 years?
Does the patient have any artificial joints, heart valves or vascular grafts?
Have you ever been told the patient requires antibiotics prior to dental treatment?
Is the patient on any medications? Please specify:
Is the patient allergic to any of the following?
Latex
Local anesthetics
Metals
Other (please specify)
Is the patient allergic to any medications? Please specify:
Does the patient carry an EpiPen for any allergies?
For the following questions, please mark Yes, No or Don't Know:
Now or in the past, has the patient ever been diagnosed or treated for:
Asthma
Yes
No
Don't Know
Ear infections
Yes
No
Don't Know
Mouth breathing
Yes
No
Don't Know
Snoring/sleep apnea
Yes
No
Don't Know
Frequent colds
Yes
No
Don't Know
Frequent canker or cold sores
Yes
No
Don't Know
Sinus problems
Yes
No
Don't Know
Frequent headaches or migraines
Yes
No
Don't Know
Adenoid problems
Yes
No
Don't Know
Adenoid removal
Yes
No
Don't Know
Tonsilitis
Yes
No
Don't Know
Tonsil removal
Yes
No
Don't Know
Diabetes
Yes
No
Don't Know
Gland or endocrine problems
Yes
No
Don't Know
Liver problems
Yes
No
Don't Know
Hepatitis/Jaundice
Yes
No
Don't Know
Bone disorders
Yes
No
Don't Know
Cancer, tumors or growths
Yes
No
Don't Know
Congenital abnormalities
Yes
No
Don't Know
Seizures/Epilepsy
Yes
No
Don't Know
Tendency to get faint or dizzy
Yes
No
Don't Know
Blood disorders
Yes
No
Don't Know
Anemia
Yes
No
Don't Know
Prolonged bleeding
Yes
No
Don't Know
Blood transfusion
Yes
No
Don't Know
Pneumonia
Yes
No
Don't Know
Tuberculosis
Yes
No
Don't Know
Thyroid disorder
Yes
No
Don't Know
Kidney problems
Yes
No
Don't Know
Stomach problems
Yes
No
Don't Know
Autoimmune disorder
Yes
No
Don't Know
Rheumatic fever
Yes
No
Don't Know
Heart condition
Yes
No
Don't Know
Sexually transmitted infection
Yes
No
Don't Know
HIV
Yes
No
Don't Know
Mental illness, anxiety or depression
Yes
No
Don't Know
Autism spectrum disorder
Yes
No
Don't Know
Please provide any other relevant details on medical history or family history:
Dental History
General Dentist Name:
Last dentist visit:
Check-up frequency:
Frequency of brushing/flossing:
How has the patient’s past experience been with dental treatment?
Has the patient seen any dental specialists?
Periodontist
Endodontist
Oral Surgeon
Prosthodontist
Has the patient had any specialty procedures?
Root Canals
Large Fillings
Crowns
Bridges
Other (please specify)
Please specify:
Has the patient been diagnosed with gum or periodontal disease?
Are you aware of any outstanding dental treatment that needs to be completed?
Has the patient had any tooth extractions?
Does the patient have any missing or extra teeth that you are aware of?
Has the patient ever injured their head or face, or broken any teeth?
Do you have any other tooth concerns or issues?
Temperature sensitivity
Bleeding gums
Wisdom teeth
Irritation
Motivation for Orthodontic Treatment
What is the main concern?
Spaces
Crowding
Appearance
Jaw pain
Bite
Tooth wear
Referral
Please provide any specific details about your concerns:
Has the patient had previous orthodontic consultation or treatment?
Any speech difficulties or speech therapy?
Does the patient grind or clench their teeth?
Does the patient have any oral habits, such as thumb sucking, lip/nail biting or pacifier use?
Does the patient have any problems eating, chewing or swallowing?
Does the patient have any jaw issues?
Muscle soreness
Pain when opening or closing mouth
Clicking or popping noises
Current or previous treatment for TMJ
Do you or the patient have any hesitancy toward pursuing orthodontic treatment?
Is there any other information you would like us to know?