*First Name:
 
Middle Initial:
*Last Name:
 
I prefer to be called:
*Birthdate:
 
Age:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Telephone:
*2nd/Cell phone:
*Email:

Dentist:
City:
Telephone:
Physician:
City:
Telephone:

School:
City:
Grade:
Sports/hobbies/etc.
Parents/Guardians
Parent/Guardian 1:
Phone Number:
Email:
Occupation:
Employer's name and address:

Parent/Guardian 2:
Phone:
Email:
Occupation:
Employer's name and address:

Parent/Guardian 3:
Phone Number:
Email:
Occupation:
Employer's name and address:

Parent/Guardian 4:
Phone:
Email:
Occupation:
Employer's name and address:

Names and birthdates of brothers and sisters:
Other family members with similar dental conditions (names and ages):
Other family members with orthodontic treatment (including parents):
Have you had any other experience with another orthodontist?
Dr.
Date of last dental check-up:
Brushing teeth:
Injury or trauma to the face or teeth:
Does the patient play a musical instrument?
Thumb sucking:
At what age?
Oral Habits (lip biting, nail biting, etc.): Specify:
Airway/Sleep Habits:
Bruxism (grinds teeth):
Jaw joint (TMJ):
Speech:
Difficulty in pronounciation:
Speech Lessons
General Health:
Height:
Weight:
Presently under medical care for:
Birth Defects:
Medication currently being taken (drug and dose):
Allergies:
Latex Allergies
Do you need to premedicate for dental appointments due to heart disorder/murmur?

Please select YES or NO to the following and date:
Adenoids (Removed)
Year:
Heart disorder/murmur
Year:
Arthritis
Year:
Hepatitis
Year:
Blood/bleeding problems
Year:
HIV
Year:
Bone Disorder
Year:
Hospitalized
Year:
Diabetes
Year:
Lung disorder
Year:
Ear/nose Infections
Year:
Rheumatic Fever
Year:
Emotional
Year:
Scoliosis
Year:
Endocrine
Year:
Speech difficulty
Year:
Epilepsy
Year:
Tonsils (removed)
Year:
Fainting spells
Year:
STD
Year:
Glaucoma
Year:
Asthma
Year:
Please give any additional information or details necessary
Have you grown very much in the past year?
How many inches?
Female patients: Monthly periods?
Started at Age:
Male Patients: Voice change?
Facial hair?
Other indications of development:
Describe major reason for seeking orthodontic treatment:
How did you become aware of the orthodontic problem?
Patient's interest in treatment:
How and when did you first hear about our office?
Whom may we thank for referring you to our office?
Any additional comments:
Responsible Party Legal First Name:
Responsible Party Legal Last Name:
Phone:
Email:
Responsible Party Address (If different from patient):

Additional Responsible Party Legal First Name:
Additional Responsible Party Legal Last Name:
Phone:
Email:
Additional Responsible Party Address (If different from patient):

Do you have orthodontic insurance?
If yes, insurance will be verified prior to your appointment with the following information:
Name of Insurance Company:
Subscriber ID#:
Subscriber Name:
Employer's Name:
Subscriber Birthdate:
Group #:
Subscriber Social Security#:
Subscriber Phone:
Subscriber Email:
If dual orthodontic insurance, please fill out the following information:
Name of Insurance Company:
Subscriber ID#:
Subscriber Name:
Employer's Name:
Subscriber Birthdate:
Group #:
Subscriber Social Security #:
Subscriber Phone:
Subscriber Email:
Please bring all of your insurance information to your first appointment.
HIPAA Notice of Privacy Practices
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. Records made in the process of examinations, treatment, and retention may be used for purposes of consultations with other professionals, research, education, or publication in journals. In addition, we are required to safeguard patient information sent via email by using encrypted coding. This is to ensure the information within the message is read by the intended recipient only. If you would like to receive emails unencrypted, you have the right to request a change. Please be advised that by doing so may result in email interception by an unauthorized third party. All patient specific, treatment information emailed to your dentist or other dental professional will still be sent encrypted. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.
 
Questionnaire completed by:
Relation to patient: