Relationship to Patient:
What is the patient's main orthodontic concern?
If any of the above dental questions were answered 'Yes', please explain:
If any of the above TMJ questions were answered 'Yes', please explain:
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
List any drug allergies or sensitivities (not listed above) that the patient may have:
If any of the above medical questions were answered 'Yes' , please explain:
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?
Face - If your facial appearance could be changed, what would you change?
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.
Has either biological parent ever had orthodontic treatment: