Patient Biographical Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
*Address:
*City:
*State:
*Zip:
Occupation:
Address:
*Main Phone:
2nd/Cell Phone:
Email:
   
Employer or School:
Work/School Phone:
Patient's Dentist:
Patient's Physician:
Address & Phone:
Address & Phone:
Please list the names and ages of any siblings below:
Please list the names of any family members or friends treated at Feldman Orthodontics below:
Describe the orthodontic problem in your own words (i.e. what problem would you like to see corrected?):
Whom may we thank for referring you to our practice?
Who noticed the orthodontic problem?
Have you consulted an orthodontist previously?
What concerns you the most about the thought of orthodontic treatment?
Other:
Have you had any previous orthodontic treatment?
Other:
  Responsible Party Information    
 
 
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Relationship to Patient:
Employer:
Work Phone #:
 
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Relationship to Patient:
Employer:
Work Phone #:
Emergency/Alt. Contact Phone: Relationship to pt.:
  Dental History     
Check-up Frequency:
Last Dental Visit:  
Is there flouride in your drinking water?
Are you on a flouride supplement?
Thumb/finger sucking habit present?
Any facial or dental injuries?
Do you play a musical instrument?
Any unfinished care to be completed by your dentist?
Have you noticed any changes in your bite or dental alignment recently?
   
What concerns has your dentist express regarding your bite or dental alignment recently?
Wear or fracture of teeth?
Bone or gum tissue loss?
Jaw or muscle tightness?
Please answer YES if there is a history of:
Muscular soreness around head and neck?
Mouth breathing while awake?
Speech problems?
Clenching/Grinding Teeth?
Periodontal "Gum Problems"?
Jaw joint soreness?
Ringing in ears?
   
 Brand & Amount
 Previous habit?
 Explain:
 Which instrument?
 Explain:
 Explain:
   
   
Difficulty with cleaning related to tooth alignment?
Alignment of teeth prior to dental work (crowns, bridges, etc.)
 Other:
   
Mouth breathing while asleep?
"Dead Teeth", root canals treated
 Sounds:
Headaches (more than normal)?
Bleeding gums, bad taste, mouth odor?
Jaw joint popping/clicking?
 Other:
Is there any other information that my be helpful?
   Medical History     
A parent/guardian must answer the following questions for children under 18 years of age. Your answers will be kept confidential and will be an aid in selecting the safest and most effective means of providing orthodontic care.
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Have you experienced any health problems?
 Explain:
Any major change in your health recently?
 Explain:
Are you currently under a physician's care?
 Explain:
Are you currently taking medications? (including Accutane)
 Explain:
Are you allergic to any medications? (e.g. penicillin or sulfa)
 Explain:
Do you have any other allergies? (e.g. latex or nickel)
 Explain:
Have you ever been seen by a cardiologist?
 Explain:
Have you been told to premedicate before cleaning visits?
 Explain:
Any surgically placed prostheses? (e.g. hip replacement)
 Explain:
Have you ever received a blood transfusion?
 Explain:
Have your tonsils or adenoids been removed?
 Explain:
Have you ever been hospitalized/had an operation?
 Explain:
Women: Are you currently taking birth control?
Are you, or do you think you may be, pregnant?
 How many weeks?
Maturation Status:
Heart Murmur
Heart Surgery
Kidney Disease
Bone Disorders/Bone Loss
Liver Disease
Growth Disorders
AIDS/HIV Infection
Tonsilitis
Epilepsy
Hepatitis
Diabetes
Cancer
Bronchitis
Tuberculosis
Received Radiation Treatment
Blood Disease
Asthma
Fainting
Frequent Headaches
Nervous/Anxious
Rheumatic Fever
Endocrine Disorders
Prolonged Bleeding
Developmental Disorder
High Blood Pressure
Chest Pain
ADHD/Related
Is there any other conditon or problem that you think we should know about?
To the best of my knowledge, the answers I have given are accurate. I also understand that it is very important to report any changes in my medical or dental status to Feldman Orthodontics at the earliest possible time, and I agree to do so. I give permission to Feldman Orthodontics to obtain from my physician any additional information regarding my medical history that might be needed to provide me with the best treatment possible.
  Name of Person Completing Form