*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Occupation:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Work Phone:
Cell Phone:
Email:
Please list the names of any family currently in the practice:
Whom may we thank for referring you to our practice?
In case of emergency, who should we contact?
Relationship to patient:
Phone #:
Dentist Name:
Last Dental Visit:
Have you visited an orthodontist in the past?

If so, when?
Explain:
What is your main orthodontic concern?
Please select YES if you have had any of the conditions listed below either now or in the past.
Speech problems/therapy?

Grind or clench teeth?

Oral habits (thumb/finger sucking, lip/nail biting)?

Injury to face, jaw, teeth or mouth?

Sensitive teeth or gums?

Pain, noise, or locking in either jaw?

Mouth breathing?

Snores during sleep?

Requires premedication for dental visit?

Any missing or extra permanent teeth?

Apprehensive about dental care?

Soreness in jaw or face muscles?

Have you ever been treated for TMJ or TMD?

If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications you are currently taking:
List any allergies or drug sensitivities you may have:
Do you smoke or have you in the past?
Please select YES if you have had any of the conditions listed below either now or in the past.
Rheumatic Fever, Heart Defect, or Heart Murmur

Lung Disease

Liver Disease

Kidney Disease

Heart Attack/Stroke or Heart Disease

Family History of Jaw Imbalance

Blood Disorder

Hypertension/High Blood Pressure

Immune System Problems

HIV/AIDS

History of Eating Disorder

Tonsils/Adenoids Removed

ADD/ADHD

Cancer

Family History of Cancer

Received Radiation Treatment or Chemotherapy

Endocrine Problems

Hormone Therapy

Latex/Metal Allergy

Mental Health Disturbance

Bone Disorders/Bone Loss

Diabetes

Seizures/Epilepsy or Other Neurological Problems

Been Diagnosed with Sleep Apnea

Asthma

Arthritis

Ever Been Hospitalized (Other than for giving birth)

Pneumonia

Osteoperosis

Women: Are you pregnant or attempting to be become pregnant?

If any of the above medical questions were answered 'Yes' , please explain:
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Do you have insurance that covers orthodontics?

If so, please name the Insurance Company below:
Primary Insurance
Primary Insurance Company
Phone#:
Group #:
Subscriber Name:
Subscriber DOB:
Subscriber #
Subscriber Employer:
Relationship:
Secondary Insurance
Secondary Insurance Company
Phone#:
Group #:
Subscriber Name:
Subscriber DOB:
Subscriber #:
Subscriber Employer:
Relationship:

I authorize Moin Orthodontics to submit insurance claims on my behalf, or my child's behalf if signing for a minor. I authorize the release of any medical or other information necessary to process my claims.

Signature:
Date: