Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Age:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
School:
Grade:
Patient's Interests or Hobbies:
Sibling Names and Ages:
Patient's 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 reasons for seeking orthodontic consultation:
Suggested By Dentist
Crowding
Spacing
Bad Bite
Overbite
Excessive Wear
Other:
Responsible Party Information
Father's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
How long at this address?
Living With Patient
Yes
No
Father's Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Birthdate:
Social Security Number:
Email:
Home Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone:
Mother's First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
How long at this address?
Living With Patient?
Yes
No
Mother's Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Birthdate:
Social Security Number:
Email:
Home Phone:
Cell Phone:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Insured's Name:
Insured's ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insured's Employer:
Insurance Company Address:
City:
State:
Zip:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Insured's Name:
Insured's ID:
Group Number:
Insurance Company Name:
Insurance Company Phone:
Insured's Employer:
Insurance Company Address:
City:
State:
Zip:
Medical History
Physician Name:
City:
Last Seen:
Is the patient experiencing any health problems?
No
Yes
If yes, explain:
Does the patient have any history of major illness?
No
Yes
If yes, explain:
Is the patient currently taking medications or drugs?
No
Yes
If yes, please list:
Is the patient allergic to any medications or drugs?
No
Yes
If yes, please list:
Has the patient's tonsils or adenoids been removed?
No
Yes
What age:
Has the patient been diagnosed or treated for any of the following:
ADD, ADHD
No
Yes
Anemia
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Bone Disorder
No
Yes
Cancer
No
Yes
Developmental Disorder
No
Yes
Diabetes
No
Yes
Dizziness
No
Yes
Epilepsy
No
Yes
Emotional Disorder
No
Yes
Fainting
No
Yes
Growth Disorder
No
Yes
Head or Neck Pain
No
Yes
Heart Disease
No
Yes
Heart Murmur
No
Yes
Hepatitis
No
Yes
HIV or AIDS
No
Yes
Liver Disease
No
Yes
Nervousness
No
Yes
Prolonged Bleeding
No
Yes
Respiratory Disorders
No
Yes
Rheumatic Fever
No
Yes
Tuberculosis
No
Yes
Other conditions or problems not mentioned above:
Emergency Contact Information
Name:
Phone:
Dental History
Started teething very early or late?
No
Yes
Primary (baby) teeth removed that were not loose?
No
Yes
Has patient had any unpleasant experiences in a dental office?
No
Yes
Injuries to face, mouth, or teeth?
No
Yes
Thumb or finger sucking habit? Until what age?
No
Yes
History of speech problems?
No
Yes
Abnormal swallowing habit (tongue thrusting)?
No
Yes
Mouth breathing habit, difficulty breathing?
No
Yes
Missing or 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 sleep?
No
Yes
Is the patient concerned about appearance of teeth?
No
Yes
Would patient mind wearing braces if needed?
No
Yes
Has the patient had any previous orthodontic treatment?
No
Yes
Has an orthodontist been consulted previously?
No
Yes
Has any family member had orthodontic treatment? If yes, who?
No
Yes
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.
Parent/Guardian Signature:
Date: