OU Graduate Orthodontics
Confidential Patient Information
*First Name:   Middle Initial: *Last Name:   Nickname:	*Birthdate:     *Gender: Male Female
*Address:   *City:   *State:   *Zip:   *Main Phone:   2nd/Cell Phone: Email: Social Security #: If patient is a minor, give parent's or guardian's name: If patient is a minor, who does the patient live with?    Select... Father Mother Father & Mother Please list the names of any friends or family currently in the practice: Please list the names and ages of all siblings: List any sports, hobbies, or musical instruments played: Whom may we thank for referring you to our practice?

Confidential Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:   Middle Intial: *Last Name:   Marital Status: Select... Single Married Partnered Widowed Divorced Separated How long at this address? *Main Phone:   2nd/Cell Phone: Email: *Birthdate:     Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other	*Address:   *City:   *State:   *Zip:   Previous Address (less than 3 years) Social Security #: Employer: Occupation: Length of Employment: Work Phone #:
Spouse or Other Parent's First Name Middle Initial: Last Name: Social Security #: Employer:	Occupation: Birthdate:   Length of Employment: Work Phone #: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other

Dental Insurance Information     Primary Dental Insurance Policy Holder's Name: Insurance Company: Subscriber ID #: Group No.: Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.: Policy Holder's Employer: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Do you have dual dental coverage? NoYes   (If yes, complete information below) Secondary Dental Insurance
Policy Holder's Name: Insurance Company: Subscriber ID #: Group No.: Insurance Co. Address: City: State: Zip: Insurance Co. Phone No.: Policy Holder's Employer: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other
Emergency Information     Name of nearest relative not living with you: Complete Address: Phone: Relationship to Patient: Select... Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other
Dental History
Dentist Name: Check-up Frequency:    Once per year Twice per year More than twice per year Never Emergencies only Last Dental Visit:	Has the patient had an orthodontic consultant or treatment? NoYes If so, when?
What is the patient's main orthodontic concern?
Does the Patient need to premedicate prior to dental visit?     NoYes
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
NoYes Speech problems/therapy?   NoYes Clench or Grind Teeth?   NoYes Oral habits (thumb/finger/blanket sucking, lip/nail biting)?   NoYes Injury to face, jaw, teeth or mouth?   NoYes Discomfort from teeth or gums?   NoYes Pain, tenderness or noise in either jaw?   NoYes Frequent headaches?   NoYes Neck/shoulder pain?   NoYes Frequent sore throats?   NoYes Chipped or injured permanent teeth?   NoYes Teeth sensitive to hot or cold?   NoYes Poor vision?   NoYes Bad taste/mouth odor?   NoYes Previous periodontal (gum) treatment?   NoYes Abnormal swallowing (tongue thrust)?   NoYes Teeth that irritate tongue, cheek, lip, etc?   NoYes Hearing difficulties?	NoYes Brush teeth daily?   NoYes Floss teeth daily?   NoYes Fluoride treatments?   NoYes Mouth breathing?   NoYes Snores during sleep/Sleep walking?   NoYes Any missing or extra permanent teeth?   NoYes Apprehensive about dental care or braces?   NoYes Frequently chew gum?   NoYes Thumb or finger habit as a child?   NoYes Ear problems?   NoYes Bleeding gums?   NoYes Fainting and dizziness?   NoYes Frequent canker sores or cold sores?   NoYes Skin problems?   NoYes Asthma or wheezing?   NoYes Is all dental work completed at this time?   NoYes Congenital disability or birth defects?
If any of the above dental questions were answered 'Yes', please explain:

NoYes	Have you had a TMJ screening?	NoYes	Do you experience soreness in the muscles of your face or around your ears?
NoYes	Do you have a history of jaw joint problems?
NoYes	Have you been treated for "TMJ"?	NoYes	Do you notice clicking or popping in your jaw joint?
NoYes	Do you clench your teeth?
NoYes	Has your jaw ever locked?	NoYes	Do you have difficulty chewing or opening your mouth?
NoYes	Does your bite feel uncomfortable or unusual?

If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Physician Name: Address: City: State: Zip:	Date of Last Physical: Patient Health: Good Excellent Fair Poor
Is the patient current on their immunizations?      NoYes
Has there been any change in the patient's general health within the last year?      NoYes
Is the patient currently under the care of a physician (other than routine)? If so, what is being treated?      NoYes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?      NoYes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
NoYes Latex   NoYes Penicillin or other antibiotics   NoYes Sulfa drugs   NoYes Aspirin, Ibuprofen, Tylenol   NoYes Local anesthetics   NoYes Codeine or other narcotics     NoYes Other: List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
NoYes Heart Murmur   NoYes Damaged or artificial heart valves   NoYes Congenital Heart Defect   NoYes Heart Disease   NoYes Rheumatic Fever   NoYes Angina   NoYes Liver Disease / Jaundice / Hepatitis   NoYes Kidney Disease   NoYes Heart Attack/Stroke   NoYes Hemophilia   NoYes Hypertension/High Blood Pressure   NoYes Prolonged Bleeding/Transfusion   NoYes Anemia / Blood disorder   NoYes HIV/AIDS   NoYes Tonsils/Adenoids Removed   NoYes Handicaps/Disabilities   NoYes Arthritis / Joint problems   NoYes Large Tonsils   NoYes Sinus trouble   NoYes Bed wetting   NoYes Substance abuse problem (past or present)   NoYes Bone fractures/trauma to face/jaw   NoYes Prosthetic joints   NoYes Chronic fatigue	NoYes Diabetes   NoYes Growth Problems   NoYes Tuberculosis or Lung Disease   NoYes Pneumonia   NoYes Cancer   NoYes Family History of Cancer   NoYes Received Radiation Treatment   NoYes Arteriosclerosis   NoYes Thyroid / Endocrine Problems   NoYes Stomach ulcer or hyperacidity   NoYes Hormone Therapy   NoYes Metal Allergy   NoYes Nervous Disorders   NoYes Bone Disorders/Bone Loss   NoYes Seizures / Epilepsy / Neurological Disease   NoYes Treated for Emotional Problems   NoYes Asthma   NoYes Respiratory problems / Emphysema   NoYes Persistent swollen neck glands   NoYes Sexually transmitted disease   NoYes Low blood pressure   NoYes Persistant cough   NoYes FEMALES: Are you pregnant   NoYes Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.) Teeth - If your teeth could be changed, how would you like them to change? Straighten Front Teeth UpperLower Straighten Back Teeth UpperLower Move Upper Teeth ForwardBackward Move Lower Teeth ForwardBackward Eliminate Spaces Between Teeth UpperLower Eliminate Crowding of Teeth UpperLower Make Line of Upper Teeth More Level Other   Face - If your facial appearance could be changed, what would you change? Move Upper Lip ForwardBackward Move Lower Lip ForwardBackward Show my teeth when I smile MoreLess Show my gums when I smile MoreLess Make my nose LongerShorter Get rid of sag under lower jaw Move chin: ForwardBackward Move chin: LeftRight

Reduce the strain when I close my lips in my	ChinLips
When my teeth touch make my lips	Closer TogethorFarther Apart
Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.
In front of ears LeftRight Below ears LeftRight Above ears LeftRight In my ears LeftRight My temples LeftRight My eyes LeftRight My neck LeftRight My shoulders LeftRight My jaw joints LeftRight My teeth   My sinuses   Other:
Patients Under 18
If patient is under the age of 18, please answer the following questions: Height: Weight: School: Grade: Has patient begun puberty: NoYes If patient is a girl, has menstruation begun: NoYes If patient is a boy, has their voice changed or have facial hair: NoYes Has the patient grown in the past year or has their shoe size changed recently: NoYes Has either biological parent ever had orthodontic treatment: Don't know No Yes   I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice. I understand that where appropriate, credit bureau reports may be obtained.