Patient Biographical Information  
*First Name:
Middle Initial:
*Last Name:
Prefers to be addressed by:
*Sex:
*Age:
*Birthdate:
Referred by:
*Address:
*City:
*Zip:
*Phone:
Employed by:
Occupation:
Work Phone:
Marital Status:
Spouse's Name:
Employed by:
Occupation:
Work Phone:
Person Responsible for the account:
Email:
Address:
Business Phone:
Home Phone:
Dental Insurance
Primary Insurance Co. Name:
Insured's Name:
Gr.#:
Insurance ID or SS #:
Is Ortho Coverage:
Insured's Birthdate:
Insured's Employer:  
Other Insurance Information:   
  Dental History   
Patient's Dentist: Last Dental Visit:  
Address:
City:
State:
Zip
Please select YES or No for the Following Questions - Do Not Leave Blank
Have there been any injuries to the face, mouth, or teeth?
Have you had or do you presently have any of the following habits?  
 
Have you been informed of any missing or extra permanent teeth?
Are you aware of sores, lumps or irritated areas in the mouth?
Has an orthodontist been consulted previously?
Name: 

Date: 
Have you ever been treated for?
If so, by whom? 
   
Do you have any speech problems?
Are you frightened or anxious about orthodontic treatment?
Are you concerned about the appearance of your teeth?
Is there anything you would like to change about your smile?
If so, what? 
What aspect of dental treatment are you most concerned with?      
Reason for consultation:
Has there ever been any orthodontic treatment for any other member of your family?
Are you satisfied with the results?
   Medical History   
Physician Name:
Date of last Physical:  
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
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
          FEMALES: Are you pregnant? 
Height:
Weight: