Confidential Biographical Information    
*First Name  
Middle Initial
*Last Name  
Nickname
*Birthdate    
*Gender  
*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?   
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
  Confidential Financial Party Information    
 
*First Name  
Middle Initial
*Last Name  
Marital_Status
How long at this address?
*Main Phone  
2nd/Cell Phone
Email
*Birthdate    
Relationship to Patient
*Address  
*City  
*State  
*Zip  
Previous Address (less than 3 years)
Social Security #
Employer
Occupation
Length of Employment
Work Phone #
 
*First Name
Middle Initial
*Last Name
Social Security #
Employer
Occupation
*Birthdate  
Length of Employment
Work Phone #
Relationship to Patient
  Dental Insurance Information    
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
Do you have dual dental coverage?   If so, please name the Insurance Company below:
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
  Emergency Information    
Name of nearest relative not living with you
Complete Address
Phone
Relationship to Patient
  Dental History     
Dentist Name
Check-up Frequency   
Last Dental Visit  
Has the patient had an orthodontic consult or treatment?
If so, when?

What is the patient's main orthodontic concern?
  Does the patient need to premedicate prior to dental visit?    
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Speech problems/therapy?
  Clench or Grind Teeth?
  Oral habits (thumb/finger sucking, lip/nail biting)?
  Injury to face, jaw, teeth or mouth?
  Discomfort from teeth or gums?
  Pain, tenderness or noise in either jaw?
  Frequent headaches?
  Neck / Shoulder Pain?
  Frequent sore throats?
  Chipped or injured permanent teeth?
  Teeth sensitive to hot or cold?
  Previous root canal therapy?
  Bad taste/mouth odor?
  Previous periodontal (gum) treatment?
  Abnormal swallowing (tongue thrust)?
  Teeth that irritate tongue, cheek, lip, etc?
  Numerous fillings?
  Brush teeth daily?
  Floss teeth daily?
  Fluoride treatments?
  Mouth breathing?
  Snores during sleep?
  Any missing or extra permanent teeth?
  Apprehensive about dental care?
  Frequently Chew Gum?
  Thumb or finger habit as a child?
  Jaw fractures, cysts, mouth infections?
  Bleeding gums?
  Other periodontal (gum) problems?
  Frequent canker sores or cold sores?
  Have wisdom teeth been removed?
  Problems with food trapped between teeth?
  Is all dental work completed at this time?
If any of the above dental questions were answered 'Yes', please explain:
  Have you had a TMJ screening?   Do you experience soreness in the muscles of your face or around your ears?
  Do you have a history of jaw joint problems?
  Have you been treated for TMJ?   Do you notice clicking or popping in your jaw joint?  
  Do you clench your teeth?
  Has your jaw ever locked?   Do you have difficulty chewing or opening your mouth?  
  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
Has there been any change in the patient's general health within the last year?     
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?     
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?     
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
  Latex   Penicillin or other antibiotics
  Sulfa drugs   Aspirin, Ibuprofen, Tylenol
  Local anesthetics   Codeine or other narcotics  
  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.
  Heart Murmur
  Damaged or artificial heart valves
  Congenital Heart Defect
  Heart Disease
  Rheumatic Fever
  Angina
  Liver Disease / Jaundice / Hepatitis
  Kidney Disease
  Heart Attack / Stroke
  Hemophilia
  Hypertension / High Blood Pressure
  Prolonged Bleeding / Transfusion
  Anemia / Blood Disorder
  HIV / AIDS
  Tonsils / Adenoids Removed
  Handicaps / Disabilities
  Arthritis / Joint problems
  Large Tonsils
  Sinus Trouble
  Bed Wetting
  Substance abuse problems (past or present)
  Bone fractures / Trauma to face / Jaw
  Prosthetic Joints
  Chronic Fatigue
  Diabetes
  Growth Problems
  Tuberculosis or Lung Disease
  Pneumonia
  Cancer
  Family History of Cancer
  Received Radiation Treatment
  Arterioscloerosis
  Thyroid / Endocrine Problems
  Stomach Ulcer or Hyperacidity
  Hormone Therapy
  Latex / Metal Allergy
  Nervous Disorders
  Bone Disorders/Bone Loss
  Seizures / Epilepsy / Neurological Disease
  Treated for Emotional Problems
  Asthma
  Respiratory Problems / Emphysema
  Persistent swollen neck glands
  Sexually Transmitted Disease
  Low Blood Pressure
  Persistant Cough
  FEMALES: Are you pregnant?
  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?
 
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.
 
 
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Height
Weight
School
Grade
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Has either biological parent ever had orthodontic treatment: