Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?

Family Information (For Patients Under 18)

Father's Information
Name:
Home #:
Cell Phone:
Employer:
Work #:
Mother's Information
Name:
Home #:
Cell Phone:
Employer:
Work #:
*   Parents Marital Status:     

Siblings
Name:
Birthdate:
Name:
Birthdate:
Name:
Birthdate:
Name:
Birthdate:
Name:
Birthdate:

Person Responsible for the Account
    If other, please name: 
Address:
Email:
Home Phone:
Work Phone:
Cell Phone:

Dental Insurance

*  Do you have dental insurance?
* Dental Insurance Co.:
Phone #:
* Subscriber Name:
* Subscriber Birthdate:
* Subscriber Employer:
* Subscriber SS/ID#:
Group #:

Secondary Insurance Co.:
Phone #:
Subscriber Name:
Subscriber Birthdate:
Subscriber Employer:
Subscriber SS/ID#:
Group #:

Dental History

Dentist Name:
Dentist Address:
Dentist Phone:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?  
What is the patient's main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* 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?
* 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?
* Periodontal disease?
* Oral habits (thumb/finger sucking, lip/nail biting)?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
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 these apply to the Patient.
* 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
* Medication Allergy
* 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
* Have you ever taken any bisphosphonates medications?
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:
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 Individual Completing Form:
* Relationship to Patient:
* Date:
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