Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
DOB:
*
Gender:
Male
Female
Marital Status:
Single
Married
Divorced
Widowed
Significant Other
*
Home Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
*
Primary Phone #:
2nd Phone #:
Email:
Mother/Guardian Information
First Name:
MI:
Last Name:
Father/Guardian Information
First Name:
MI:
Last Name:
Please list the names of any family members currently in our practice.:
Dental Insurance Information
Primary Insurance
*
Policy Holder's Name:
*
Policy Holder DOB:
*
Insurance Company
And
Address:
*
Insurance Co. Phone No.:
*
Policy Holder ID #:
*
Group #:
*
Employer:
Secondary Insurance
*
Policy Holder's Name:
*
Policy Holder DOB:
*
Insurance Company
And
Address:
*
Insurance Co. Phone No.:
*
Policy Holder ID #:
*
Group #:
*
Employer:
Dental History
General Dentist:
Date of Last Exam:
What are the main concerns you would like to accomplish with orthodontics?
How did you hear about us?
Internet
Ad
Family/Friend
Dentist
Other
Name of the person who referred you.
Have you ever visited an orthodontist?
No
Yes
If so, when?
If so, reason for orthodontic consult?
*
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
No
Yes
*
Do you have any extra or missing teeth?
No
Yes
Have you ever had an injury to (select any that apply):
Teeth
Mouth
Chin
*
Have you had a recent panoramic x-ray taken?
No
Yes
If so, where?
*
Do you have any speech problems?
No
Yes
If so, please explain:
Do you have or have you ever had any of the following habits. Cannot be blank.
*
Clenching/Grinding Teeth?
No
Yes
*
Mouth breathing?
No
Yes
*
Nail Biting?
No
Yes
*
Thumb/Finger Sucking?
No
Yes
*
Lip Sucking/Biting?
No
Yes
*
Chewing/Eating Problems?
No
Yes
Medical History
*
Do you have any history of major illnesses?
No
Yes
*
Are you allergic to any medications, food or anything else?
No
Yes
Are you currently taking any medications? If yes, please list with dosages.
No
Yes
*
Do you need to be pre-medicated for appointments due to a medical condition?
No
Yes
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
*
Abnormal Bleeding
No
Yes
*
ADHD
No
Yes
*
AIDS or HIV positive
No
Yes
*
Arthritis
No
Yes
*
Asthma
No
Yes
*
Autism
No
Yes
*
Cancer
No
Yes
*
Cerebral Palsy
No
Yes
*
Cleft Palate
No
Yes
*
Diabetes
No
Yes
*
Seizures / Epilepsy
No
Yes
*
Hearing Problems
No
Yes
*
Heart Disease
No
Yes
*
Heart Murmur
No
Yes
*
Hemophilia
No
Yes
*
Hepatitis
No
Yes
*
High or Low Blood Pressure
No
Yes
*
Hospital Stays/Surgeries
No
Yes
*
HPV
No
Yes
*
Kidney Problems
No
Yes
*
Liver_Problems
No
Yes
*
Osteoporosis/Osteopenia
No
Yes
*
Sickle Cell Anemia
No
Yes
*
Speech/Breathing Problems
No
Yes
*
Tobacco Use
No
Yes
*
Tuberculosis
No
Yes
Other
Does your child have an IEP at school?
No
Yes
Please rate the following with 5 being the most important and 1 being the least.
*
Comfort of treatment:
1
2
3
4
5
*
Length of treatment:
1
2
3
4
5
*
Clear or invisible treatment options:
1
2
3
4
5
*
Latest technology for treatment:
1
2
3
4
5
*
Low down payment:
1
2
3
4
5
*
Low monthly payments:
1
2
3
4
5
*
Starting treatment as soon as possible:
1
2
3
4
5
I understand that the information that I have provided is correct to the best of my knowledge. I agree to inform this practice of any changes in my medical or dental history. In addition I authorize Edina Orthodontics to perform a complete orthodontic evaluation.