Patient Biographical Information  
*First Name:
Middle Initial:
*Last Name:
Prefers to be addressed by:
School:
*Sex:
*Age:
*Birthdate:
Referred by:
Grade:
*Address:
*City:
*Zip:
*Phone:
Father's Name:
Employer's Name and Address:
Work Phone:
Occupation:
How Long Employed:
Mother's Name:
Employer's Name and Address:
Occupation:
Work Phone:
How Long Employed:
Parent's Marital Status:
Person Responsible for the account:
Email:
Address:
Business Phone:
Home Phone:
Please list the name and birthdate of any siblings:
Height: Weight:
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:
Dental Insurance
Primary Insurance Co. Name:
Insured's Name:
Gr.#:
Insured ID or SS #:
Is Ortho Coverage:
Birthdate:
Insured's Employer:  
Other Insurance Information:    Insured/member ID or SS# : 
  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?
If any of the above dental questions were answered 'Yes', please explain:
   Medical History   
Physician Name:
Address:
City:
State:
Zip:
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 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
If any of the above medical questions were answered 'Yes' , please explain: