Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Gender:
Male
Female
Other
Social Security #:
Birthdate:
Age:
Email:
Address:
City:
State:
Zip:
Years At This Address:
Home Phone:
Cell Phone:
Work Phone:
Occupation:
Employer:
Years Employed:
Spouse's First Name:
Middle Initial:
Last Name:
Birthdate:
Age:
SSN:
Email:
Home Phone:
Cell Phone:
Work Phone:
Occupation:
Employer:
Years Employed:
Patient's Interest or Hobbies:
Names and Ages of Children at Home:
Name of Dentist:
Date of Last Visit:
Whom may we thank for referring you to our office?
Do you know any patients in our practice? Who?
Please check the reasons for seeking an orthodontic consultation:
Suggested By Dentist
Crowding
Spacing
Bad Bite
Other
Would You Prefer:
Braces
Aligners
Doctor Reccomendation
Financial Party Information
(if different)
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
How long at this address?
Email:
Home Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Policy Holder's Name:
Subscriber ID:
Insurance Company Name:
Group Number:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Subscriber ID:
Insurance Company Name:
Group Number:
Insurance Company Phone:
Insurance Company Address:
City:
State:
Zip:
Policy Holder's Employer:
Medical History
Physician Name:
City:
Last Seen:
Are you experiencing any health problems?
No
Yes
If yes, explain:
Do you have any history of major illness?
No
Yes
If yes, explain:
Are you currently taking medications or drugs?
No
Yes
If yes, please list:
Are you allergic to any medications or drugs?
No
Yes
If yes, please list:
Women: Are you pregnant?
No
Yes
Have you been diagnosed or treated for any of the following?
Anemia
No
Yes
Diabetes
No
Yes
Head or Neck Pain
No
Yes
Nervousness
No
Yes
Arthritis
No
Yes
Dizziness/Vertigo
No
Yes
Heart Disease
No
Yes
Prolonged Bleeding
No
Yes
Asthma
No
Yes
Epilepsy
No
Yes
Heart Murmur
No
Yes
Respiratory Disorders
No
Yes
Bone Disorder
No
Yes
Emotional Disorder
No
Yes
Hepatitis
No
Yes
Rheumatic Fever
No
Yes
Cancer
No
Yes
Fainting
No
Yes
HIV or AIDS
No
Yes
Tuberculosis
No
Yes
Other conditions or problems not mentioned above:
Emergency Contact Information
Name:
Phone:
Dental History
Injuries to face, mouth, or teeth?
No
Yes
History of speech problems?
No
Yes
Abnormal swallowing habit (tongue thrusting)?
No
Yes
Mouth breathing habit, difficulty breathing?
No
Yes
Missing permanent teeth?
No
Yes
Extra permanent teeth?
No
Yes
Periodontal (gum) problems?
No
Yes
Any teeth irritating cheek, lip, or tongue?
No
Yes
Clicking or popping of the jaw?
No
Yes
Difficulty in opening, closing, or chewing?
No
Yes
Pain or soreness in muscles of face or around the ears?
No
Yes
Clenching or grinding of the teeth while awake or asleep?
No
Yes
Have you had any previous orthodontic treatment?
No
Yes
Has an orthodontist been consulted previously?
No
Yes
Who?
Date:
Have any family members had orthodontic treatment?
No
Yes
Who?
Any other information that may be helpful?
If there are any changes to this history record or medical/dental status, I will so inform this practice.
Signature:
Date: