*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:

List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

*First Name:
Middle Initial:
*Last Name:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
Email:
*Main Phone:
2nd/Cell Phone:
Social Security #:
Work Phone #:
Employer:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
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:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
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.
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Brush teeth daily?
Floss teeth daily?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Have you been treated for "TMJ"?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Patient Health:

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Other:
List any drug allergies or sensitivities (not listed above) 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
Heart Disease
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Anemia / Blood disorder
HIV/AIDS
Diabetes
Tuberculosis or Lung Disease
Cancer
Received Radiation Treatment
Nervous Disorders
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Sexually transmitted disease
Low blood pressure
If any of the above medical questions were answered 'Yes' , please explain: