Patient Biographical Information    
*First Name:  
Middle Initial:
*Last Name:  
*Birthdate: (mm/dd/yyyy)    
*Gender:  
Nickname:
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?
  Responsible Party Information    
Father/Guardian or Self Name:
Address:
City:
State:  Zip: 
Employed By:
Home Phone:   Cell Phone: 
Social Security #:
Email Address:
Work Phone:
Mother/Guardian Name:
Address:
City:
State:  Zip: 
Employed By:
Home Phone:  Cell Phone: 
Social Security #:
Email Address:
Work Phone:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Insured's SS #:
Insured's Birthdate: (mm/dd/yyyy)  
Insured's Employer:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Checkup: (mm/dd/yyyy, mm/yyyy)  
Has the patient had an orthodontic consultant or treatment?
If so, when? (mm/dd/yyyy, mm/yyyy)  
What is the patients main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  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?
  Neck/shoulder pain?
  Frequent sore throats?
  History of Dental Injury?
  Nailbiting?
  Thumbsucking?
  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 Chew Gum?
  Tongue sucking?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History     
Physician Name:
Date of last Physical:   (mm/dd/yyyy, mm/yyyy)
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  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:
  Patients Under 18    
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
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:

The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. In addition, I acknowledge the receipt of a copy of this office's Notice of Privacy Practices.
Date:             Name of Person Completing Form: