Patient Biographical Information
*
First Name:
Middle Initial:
*
Last Name:
Nickname:
Birthdate:
*
Gender:
Male
Female
*
Address:
*
City:
*
State:
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Cell Phone Service Provider for Text Message Reminders:
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*
First Name:
Middle Initial:
*
Last Name:
Birthdate:
*
Address:
*
City:
*
State:
*
Zip:
*
Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Cell Phone Service Provider:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Second Responsible Party
First Name:
Middle Initial:
Last Name:
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company:
Cell Phone Service Provider:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
*
Speech problems/therapy?
No
Yes
*
Grind or clench teeth?
No
Yes
*
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
*
Injury to face, jaw, teeth or mouth?
No
Yes
*
Discomfort from teeth or gums?
No
Yes
*
Pain, tenderness or noise in either jaw?
No
Yes
*
Frequent headaches?
No
Yes
*
Neck/shoulder pain?
No
Yes
*
Frequent sore throats?
No
Yes
*
Brush teeth daily?
No
Yes
*
Floss teeth daily?
No
Yes
*
Fluoride treatments?
No
Yes
*
Mouth breathing?
No
Yes
*
Snores during sleep?
No
Yes
*
Requires premedication?
No
Yes
*
Any missing or extra permanent teeth?
No
Yes
*
Apprehensive about dental care?
No
Yes
*
Frequently Chew Gum?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Address:
City:
State:
Zip:
Date of last Physical:
Patient Health:
Good
Excellent
Fair
Poor
List any medications currently being taken by the patient:
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.
*
Rheumatic Fever
No
Yes
*
Tuberculosis/Lung Disease
No
Yes
*
Pneumonia
No
Yes
*
Liver Disease
No
Yes
*
Kidney Disease
No
Yes
*
Heart Attack/Stroke
No
Yes
*
Heart Disease
No
Yes
*
Congenital Heart Defect
No
Yes
*
Heart Murmur
No
Yes
*
Hemophilia
No
Yes
*
Hypertension/High Blood Pressure
No
Yes
*
Prolonged Bleeding/Transfusion
No
Yes
*
Anemia
No
Yes
*
HIV/AIDS
No
Yes
*
Hepatitis
No
Yes
*
Tonsils/Adenoids Removed
No
Yes
If you are pregnant, what is your due date?
*
Cancer
No
Yes
*
Family History of Cancer
No
Yes
*
Received Radiation Treatment
No
Yes
*
Growth Problems
No
Yes
*
Endocrine Problems
No
Yes
*
Hormone Therapy
No
Yes
*
Latex/Metal Allergy (anyone in the household)
No
Yes
*
Nervous Disorders
No
Yes
*
Bone Disorders/Bone Loss
No
Yes
*
Diabetes
No
Yes
*
Seizures/Epilepsy
No
Yes
*
Handicaps/Disabilities
No
Yes
*
Asthma
No
Yes
*
Arthritis
No
Yes
*
Treated for Emotional Problems
No
Yes
*
Ever Been Hospitalized
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Please list the name and birthdate of any siblings: