*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:

Mother/Guardian's Name:
Father/Guardian's Name:

Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Please help us to understand your concerns or desires by sharing the following information; please be specific

General Concerns:

Teeth/Smile - Is there anything about your smile or teeth that you'd like to change?

Symptoms:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Have your teeth changed in the last five years, become shorter, thinner, or worn? If yes, please explain:
Do you wear/have you ever worn a bite appliance?

Please select YES or No for the Following Questions - Do Not Leave Blank
Speech concerns/therapy?
Snores during sleep?
Grind or clench teeth?
Diagnosis of Sleep Apnea
Injury to face, jaw, teeth or mouth?
Wake up tired after a full night of sleep
Neck/shoulder pain?
Pain, tenderness or noise in either jaw?
Discomfort from teeth or gums?
Requires premedication for dental visits?
Oral habits (thumb/finger sucking, lip/nail biting)?
Any missing or extra teeth?
Dry mouth (Sjogene's syndrome?
Frequent headaches?
Sensitive gagging reflex?
Mouth breathing?
If any of the above dental questions were answered 'Yes' or you have any other dental concerns, please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
Growth Problems
Tuberculosis/Lung Disease
Endocrine/Thyroid Problems
Pneumonia
Hormone Therapy
History of smoking
Tonsils/Adenoids Removed
Liver Disease
Diabetes
Kidney Disease
Bone Disorders/Bone Loss
Heart Disease
Seizures/Epilepsy
Heart Attack/Stroke
Faints easily
Heart Murmur
Inflamatory Rheumatism
Congenital Heart Defect
Arthritis
Hypertension/High Blood Pressure
Handicaps/Disabilities
Hemophilia
Asthma
Prolonged Bleeding/Transfusion
ADHD
Anemia
Anxiety with new experiences
Hepatitis
Nervous Disorders
HIV/AIDS
Latex/Metal Allergy
Cancer
Herpes (Oral cold sores)
Received Radiation Treatment
If any of the above medical questions were answered 'Yes' , please explain:
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
 
Relationship to Patient:
Email:
If other relationship, please explain:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Employer:
Occupation:
Work Phone #:

Primary Insurance

Dental Insurance Company Name:
Address:
Phone #:
Subscriber First Name:
Last Name:
Employer:
Subscriber ID #:
Group #:
Subscriber DOB:
Subscriber Gender:

Secondary Insurance

Dental Insurance Company Name:
Address:
Phone #:
Subscriber First Name:
Last Name:
Employer:
Subscriber ID #:
Group #:
Subscriber DOB:
Subscriber Gender:
By typing my name below, I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.