Confidential Patient Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
Other
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Social Security #:
*Email:
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?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*Birthdate:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Employer:
Occupation:
Work Phone #:
2nd/Other Parent Section
First Name:
Middle Initial:
Last Name:
Marital Status:
Select
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Employer:
Occupation:
Work Phone #:
Dental Insurance Information
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Dental Insurance Company:
SSN or Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Select
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Birthdate:
Policy Holder's Employer:
Dental Insurance Company:
SSN or Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dental History
Dentist Name:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
Does the patient need to premedicate prior to dental visit?
No
Yes
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. Cannot be blank.
Speech problems/therapy?
No
Yes
Clench or grind teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Chipped or injured permanent teeth?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Apprehensive about dental care?
No
Yes
Jaw fractures, cysts, mouth infections?
No
Yes
Bleeding gums?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Is there any dental work yet to be completed?
No
Yes
Thumb or finger habit?
No
Yes
If yes, age when stopped:
If any of the above dental questions were answered 'Yes', or if any other dental concerns, please explain:
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Do you clench your teeth?
No
Yes
If any of the above TMJ questions were answered 'Yes', or if any other TMJ concerns, please explain:
Medical History
Physician Name:
Date of Last Physical:
Address:
City:
State:
Zip:
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
No
Yes
List any medications currently being taken by the patient (include non-prescription):
Allergies or drug reaction to:
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Codeine or other narcotics
No
Yes
Other:
No
Yes
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 blank.
Heart murmur
No
Yes
Damaged or artificial heart valves
No
Yes
Congenital heart defect
No
Yes
Liver disease / Jaundice / Hepatitis
No
Yes
Heart attack / Stroke
No
Yes
Hypertension / High blood pressure
No
Yes
Prolonged bleeding / Transfusion
No
Yes
Anemia / Blood disorder
No
Yes
HIV / AIDS
No
Yes
Tonsils removed
No
Yes
Adenoids removed
No
Yes
Arthritis / Joint problems
No
Yes
Sinus trouble
No
Yes
Diabetes
No
Yes
Growth problems
No
Yes
Metal allergy
No
Yes
Bone disorders / Bone loss
No
Yes
Seizures / Epilepsy / Neurological disease
No
Yes
Treated for emotional problems
No
Yes
Asthma
No
Yes
FEMALES: Are you pregnant?
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Is there anything else we need to know about your medical history?
Patients Under 18
If patient is under the age of 18, please answer the following questions:
School:
Grade:
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
Has either biological parent ever had orthodontic treatment:
Don't know
No
Yes
*
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.