Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
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?
Financial Party Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Check if the Responsible Party's Address is the same as the Patient's.
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Do you have insurance that covers orthodontics?
Yes
No
Insurance Company:
Employer:
Dental History
Dentist Name:
Last Dental Visit:
What is the patient's main orthodontic concern?
Please select if the patient has had any of the conditions listed below either now or in the past.
Apprehensive about dental care?
Brush teeth daily?
Clench or grind teeth?
Discomfort from teeth or gums?
Floss teeth daily?
Frequent headaches?
Frequent sore throats?
Injury to face, jaw, teeth, or mouth?
Mouth breathing?
Oral habits (thumb or finger sucking, lip or nail biting)?
Pain, tenderness, or noise in either jaw?
Snores during sleep?
If any of the above dental questions apply, please explain:
Medical History
Please list any medications currently being taken by the patient (include non-prescription):
Please list any other drug allergies or sensitivities that the patient may have:
Please select if the patient has had any of the conditions listed below either now or in the past.
Asthma?
Emotional problems (treatments)?
Heart defect (congenital)?
Hepatitis?
HIV or AIDS?
Latex or Metal Allergy?
Nervous disorders?
Tonsils or adenoids removed?
Tuberculosis or lung disease?
If any of the above medical questions apply, please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
Yes
No
If patient is a girl, has menstruation begun?
Yes
No