*First Name:
MI:
*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?

*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Name of Family Physician:
Date of last visit to physician:
Are there any medical specialists you see regularly?
Specialty:
Date of last complete physical exam:
Examing doctor:
Pharmacy: Name:
Phone:
Has this patient been advised by a physician that they require an antibiotic prior to dental treatment?
If yes, Antibiotic:
How is antibiotic given?
This patient's general health at this time is:
Comment:
Is this patient presently under the care of a physician?
For what?
Is this patient presently taking medications?
If yes, which medications:
Has this patient had tonsils or adenoids removed?
Does this patient have a Chronic Illness?
Comment:
Has this patient ever had a serious illness?
Comment:
Has this patient ever been Hospitalized?
For what?
Has this patient ever had a substance abuse problem?
What substance(s)?
Has this patient ever had emotional problems?
Describe?
Does this patient have any handicaps/disabilities?
Describe?
Is this patient allergic to antibiotics (penicillin, etc)?
If yes, which medications:
Does this patient have anesthetic reactions? If yes, Local or General?
Is this patient allergic to anything else? If yes, what?
Comments:
Does this patient now have, or ever had any of the following problems
Rheumatic Fever
Hepatitis (type?)
Diabetes
Endocarditis
AIDS or HIV Positive
Epilepsy
Heart Condition
Tuberculosis
Stroke
Heart Pacemaker
Lived with tuberculin person
Stomach Ulcers
Respiratory Lung Disease
Tonsillitis
Asthma
Headaches
Venereal Disease
Earaches
Herpes (Oral Cold Sores)
Jaw Pain
Inflammatory Rheumatism
Jaw Clicking (Noise)
Arthritis
X-Ray (radiation) cancer therapy
High Blood Pressure
Glaucoma
Low Blood Pressure
Fainting Spells
Blood Disorders/Bleeding Problems
Kidney Trouble
Anemia
Liver Disease
Please comment on any YES responses:
Does this patient have any other medical problems not listed?
What is this patient's height?
Child's present age:
Is child adopted?
Any recent signs of increased growth?
If a BOY, has his voice changed?
If a GIRL, has she started menstruation?
MOTHER'S present height:
FATHER'S present height:
Name of Family Dentist:
Date of last dental visit:
How many times a day do you BRUSH?
How many times a day do you FLOSS?
Has this patient been examined by another orthodontist?
Date:
Name of orthodontist:
Has this patient ever had orthodontic treatment (braces)?
Date:
Name of dentist:
Has this patient been treated for jaw joint (TMJ) problems?
Date:
Name of dentist:
Has this patient been treated for gum disease?
If yes, what kind of treatment?
Has this patient had root canal treatment?
If yes, which teeth?
Has this patient had other dental specialist treatment?
If yes, what?
Does this patient have any oral habits?
If yes, which?
Comments:
Does this patient have any TMJ (jaw joint) Symptoms?
If yes, what symptoms?
Comments?
Does this patient have any Missing Permanent Teeth?
Comment:
Does this patient have any Extra Permanent Teeth?
Comment:
Does this patient typically have bleeding gums?
Comment:
Does this patient have sores, lumps, or irritated tissue in the mouth?
Comment:
Has this patient had any injuries to his/her teeth?
Comment:
Has this patient had any injuries to his/her face, jaws, or mouth??
Comment:
Has this patient been informed of any Speech Problems?
Comment:
Are there any other comments about this patient's dental history?
Comment:
What are this patient's concerns about his/her teeth?
Is this patient anxious about having orthodontic treatment?
Comment:
Does the family dentist have any concerns about this patient's teeth?
Comment:
Do any other family members have concerns about this patient's teeth?
Comment:
Have any members of your family received orthodontic treatment?
Mother
If yes, Dentist or Orthodontist?
Were you satisfied with the result?

Father
If yes, Dentist or Orthodontist?
Were you satisfied with the result?

Sister
If yes, Dentist or Orthodontist?
Were you satisfied with the result?

Brother
If yes, Dentist or Orthodontist?
Were you satisfied with the result?

Child
If yes, Dentist or Orthodontist?
Were you satisfied with the result?
* If no, Comment:

If your dentist has taken new full mouth or panoramic x-rays in the past six months, please bring them with you to the exam.
If you have had orthodontic records taken in the past six months, please bring them with you to the exam.
If you are currently wearing an orthodontic appliance or Bite Splint (night guard), please bring it with you to the exam.
Is there any other medical or dental condition that we should know about?

I the undersigned have completed this medical and dental health history and certify that the preceding information is true and correct. This practice cannot be held responsible for any problems arising out of inadequate information not disclosed here. If there are any future changes in this information, I will inform this practice of these changes.