Patient Biographical Information    
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:  
*Gender:
*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:
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.
ADHD
Anemia
Arthritis
Asthma
Bone Disorders/Bone Loss
Cancer
Congenital Heart Defect
Depression/Anxiety
Diabetes
Endocrine Problems
Ever Been Hospitalized
Family History of Cancer
Growth Problems
Handicaps/Disabilities
Heart Attack/Stroke
Heart Disease
Heart Murmur
Hemophilia
Hepatitis/Liver Disease
HIV/AIDS
Hormone Therapy
Hypertension/High Blood Pressure
Kidney Disease
Latex/Metal Allergy
Pneumonia
Prolonged Bleeding/Transfusion
Psychiatric Care
Received Radiation Treatment
Rheumatic Fever
Seizures/Epilepsy
Tonsils/Adenoids Removed
Tuberculosis/Lung Disease
If any of the above medical questions were answered 'Yes' , please explain:
FEMALES UNDER 18: Age of first menses:
  Financial Party Information    
 
*First Name:
Middle Initial:
*Last Name:
*Birthdate:  
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Insurance Company Phone:
Social Security #:
Employer:
Occupation:
Work Phone #:
Other person(s) authorized to make financial and treatment decisions:
Name:
Relationship:
  Dental History     
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Has the patient had an orthodontic consultant or treatment?
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.
Any missing or extra permanent teeth?
Apprehensive about dental care?
Discomfort from teeth or gums?
Frequent headaches?
Frequent sore throats?
Grind or clench teeth?
Injury to face, jaw, teeth or mouth?
Mouth breathing?
Neck/shoulder pain?
Oral habits (thumb/finger sucking, lip/nail biting)?
Pain, tenderness or noise in either jaw?
Requires premedication?
Speech problems/therapy?
Snores during sleep?
If any of the above dental questions were answered 'Yes', please explain: