* Requires Answer
Confidential Patient Information
*
First Name:
Middle Initial:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
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Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
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Zip:
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Best Phone:
2nd/Cell Phone:
Email:
Please list the names of friends or family currently in the practice:
Please list any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
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First Name:
Middle Initial:
*
Last Name:
*
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Best Phone:
2nd Phone:
Other Phone:
Do you have insurance that covers orthodontics?
Yes
No
If so, please name the Insurance Company below:
Policy Holder's Name:
Policy Holder's Date of Birth:
Policy Holder's ID Number OR Social Security Number:
Group Number:
Insurance Company Address:
Insurance Company Phone Number:
Do you have dual coverage?
Yes
No
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
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Has all the recommended work by your dentist been completed?
Yes
No
Has the patient had an orthodontic consult or treatment?
Yes
No
If so, when?
What is the main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be left blank.
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Speech problems/therapy?
Yes
No
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Clench or Grind Teeth?
Yes
No
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Injury to face, jaw, teeth or mouth?
Yes
No
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Discomfort from teeth or gums?
Yes
No
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Pain, tenderness or noise in either jaw?
Yes
No
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Frequent headaches/neck or shoulder pain?
Yes
No
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Oral habits (thumb/finger sucking, lip/nail biting)?
Yes
No
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Frequent sore throats?
Yes
No
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Mouth breathing?
Yes
No
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Snores during sleep?
Yes
No
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Requires premedication for dental procedures?
Yes
No
*
Any missing or extra permanent teeth?
Yes
No
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Apprehensive about dental care?
Yes
No
If any of the above dental questions were answered 'Yes', please explain:
Has either biological parent ever had orthodontic treatment?
Biological Mom Name:
Yes
No
Don't Know
Biological Dad Name:
Yes
No
Don't Know
Medical History
List any medications currently being taken by the patient (include non-prescription):
List any drug allergies or sensitivities 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 left blank.
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Rheumatic Fever
Yes
No
*
Tuberculosis/Lung Disease
Yes
No
*
Pneumonia
Yes
No
*
Liver Disease
Yes
No
*
Kidney Disease
Yes
No
*
Heart Attack/Stroke
Yes
No
*
Heart Disease
Yes
No
*
Congenital Heart Defect
Yes
No
*
Heart Murmur
Yes
No
*
Hemophilia
Yes
No
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Hypertension/High Blood Pressure
Yes
No
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Prolonged Bleeding/Transfusion
Yes
No
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Anemia
Yes
No
*
HIV/AIDS
Yes
No
*
Hepatitis
Yes
No
*
Tonsils/Adenoids Removed
Yes
No
*
Cancer
Yes
No
*
Family History of Cancer
Yes
No
*
Received Radiation Treatment
Yes
No
*
Growth Problems
Yes
No
*
Endocrine Problems
Yes
No
*
Hormone Therapy
Yes
No
*
Latex/Metal Allergy
Yes
No
*
Nervous Disorders
Yes
No
*
Bone Disorders/Bone Loss
Yes
No
*
Diabetes
Yes
No
*
Seizures/Epilepsy
Yes
No
*
Handicaps/Disabilities
Yes
No
*
Asthma
Yes
No
*
Arthritis
Yes
No
*
Treated for Emotional Problems
Yes
No
*
Ever Been Hospitalized
Yes
No
*
Taking (or taken in the past) bisphosphonates for cancer therapy or prevention of osteoporosis (Foramax, Actenol, Boniva, etc.)
Yes
No
If any of the above medical questions were answered 'Yes' , please explain:
I understand that the information I have provided is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in the medical status of the patient. I consent to examination by Dr. Mason, Dr. Garn and/or Dr. Doucette.
Please type name of person filling out this form:
Initials:
Date: