Patient Biographical Information
*First Name: Middle Initial: *Last Name: Nickname:	*Birthdate:   *Gender: Male Female
*Address: *City: *State: *Zip: *Daytime Phone: 2nd/Cell Phone: Email:

Patients Under 18

If patient is under the age of 18, please answer the following questions: Father/Guardian 1 Name: Mother/Guardian 2 Name: *Whom may we thank for referring you to our practice?    Medical History      Physician Name: Number: Patient Health: Good Excellent Fair Poor 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. Cannot be blank. NoYes ADHD NoYes Anemia NoYes Arthritis NoYes Asthma NoYes Bone Disorders/Bone Loss NoYes Cancer NoYes Congenital Heart Defect NoYes Depression/Anxiety NoYes Diabetes NoYes Endocrine Problems NoYes Ever Been Hospitalized NoYes Family History of Cancer NoYes Growth Problems NoYes Handicaps/Disabilities NoYes Heart Attack/Stroke NoYes Heart Disease NoYes Heart Murmur NoYes Hemophilia NoYes Hepatitis/Liver Disease NoYes HIV/AIDS NoYes Hormone Therapy NoYes Hypertension/High Blood Pressure NoYes Kidney Disease NoYes Latex/Metal Allergy NoYes Pneumonia NoYes Prolonged Bleeding/Transfusion NoYes Psychiatric Care NoYes Received Radiation Treatment NoYes Rheumatic Fever NoYes Seizures/Epilepsy NoYes Tonsils/Adenoids Removed NoYes Tuberculosis/Lung Disease If any of the above medical questions were answered 'Yes' , please explain: FEMALES UNDER 18: Age of first menses: Do you smoke or use any type of tobacco or vaping products? NoYes   Financial Party Information     Check if the patient is also the person who will be financially responsible for treatment.   *First Name: Middle Initial: *Last Name: *Birthdate:   *Address: *City: *State: *Zip: *Main Phone: 2nd/Cell Phone: Email: Relationship to Patient: Father Grandparent Guardian Mother Parents Self Spouse Step Father Step Mother Other Do you have insurance that covers orthodontics? NoYes If so, please name the Insurance Company below: Insurance Company Phone: Insurance ID#: Social Security #: Employer: Occupation: Work Phone #: Other person(s) authorized to make financial and treatment decisions: NoYes Name: Relationship:   Dental History      Dentist Name: Check-up Frequency: Once per year Twice per year More than twice a year Never Emergencies only Last Dental Visit:   Has the patient had an orthodontic consultant or treatment? NoYes If so, explain: *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. NoYes Any missing or extra permanent teeth? NoYes Apprehensive about dental care? NoYes Discomfort from teeth or gums? NoYes Frequent headaches? NoYes Frequent sore throats? NoYes Grind or clench teeth? NoYes Injury to face, jaw, teeth or mouth? NoYes Mouth breathing? NoYes Neck/shoulder pain? NoYes Oral habits (thumb/finger sucking, lip/nail biting)? NoYes Pain, tenderness or noise in either jaw? NoYes Requires premedication? NoYes Speech problems/therapy? NoYes Snores during sleep? If any of the above dental questions were answered 'Yes', please explain: