Patient Biographical Information

* First Name:
MI:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Contact Phone:
2nd Phone:
Contact Email:
I request appointment reminders via:
Spouse's Name (if applicable):

If Patient Is A Minor
Father's Name:
Address (if different):
Occupation:
Employer:
Cell #:
Email:
Mother's Name:
Address (if different):
Occupation:
Employer:
Cell #:
Email:

Please list the names of any friends or family who have been examined or treated in our office:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
* Birthdate:
Relationship to Patient:
Email:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Social Security #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Policy Holder's Name:
Relationship to Patient:
Subscriber ID #:
Group No.:
Date of Birth:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Do you have dual dental coverage?
If so, please name the Insurance Company below:
Policy Holder's Name:
Relationship to Patient:
Subscriber ID #:
Group No.:
Date of Birth:
Employer:
Occupation:
Length of Employment:
Work Phone #:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had any unusual dental experiences?
(If yes, please specify)
Have any teeth been injured due to accidents/blows to mouth?
(If yes, please specify)
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patient's main orthodontic concern?

Please mark YES for all that apply
Speech problems/therapy?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Oral habits (thumb/finger sucking, lip/nail biting)?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently chews gum?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

List any medications currently being taken by the patient:
Is the patient presently under physician's care during during the past two years other than routine exams? If yes, please specify.
Has the patient had any serious illness, operation, or been hospitalized in the past 5 years? If yes, please specify.
List any drug allergies or sensitivities that the patient may have:
Please mark YES for all that apply
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
If any of the above medical questions were answered 'Yes' , please explain:

If patient is under the age of 18, please answer the following questions:

Please list the name and age of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Signature of Patient (parent/guardian if minor):
Date