Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
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:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Do you have insurance that covers orthodontics or reimbursement?
No
Yes
If so, please give the Insurance Company details below:
Insurance Company:
Policy Holder's Name:
Insurance Co. Phone No.:
Group No.:
Member/Subscriber Id:
Policy Holder's Birthdate:
Secondary Responsible Party
If the patient is a child with married parents, please list other parent.
If the patient is a child with divorced parents, please list other biological parent.
If the patient is an adult, please list spouse if applicable.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Do you have insurance that covers orthodontics or reimburesment?
No
Yes
If so, please give the Insurance Company details below:
Insurance Company:
Policy Holder's Name:
Insurance Co. Phone No.:
Group No.:
Member/Subscriber Id:
Policy Holder's Birthdate:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Please select Yes or No for the Following Questions - Do Not Leave Blank
No to all (please read carefully)
Speech problems/therapy?
No
Yes
Clench or Grind Teeth?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
No
Yes
If any of the above require further explanation, please explain:
Medical History
Physician Name:
Year of Last Physical:
Clinic/Hospital
Mayo Clinic
Olmsted County Medical Center
Other
Emergency Contact
Please enter someone who is not already listed as a responsible party above.
Name:
Phone:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
FEMALES: Are you currently pregnant?
No
Yes
Is patient currently under medical care for any reason(s)?
No
Yes
Examples: Rheumatic Fever, Pneumonia, Kidney Disease, Hypertension/High Blood Pressure, Anemia, Hepatitis, Cancer, Received Radiation Treatment, Bone Disorders/Bone Loss, Seizures/Epilepsy, Asthma, Emotional Problems, Tuberculosis/Lung Disease Liver Disease, Hemophilia, HIV/AIDS, Growth Problems, Hormone Therapy, Nervous Disorders, Diabetes, Arthritis
If yes, please briefly describe:
Any heart problems?
No
Yes
Examples: Heart disease, heart murmur, heart attack, congential heart defect
If yes, please briefly describe?
Tonsils/Adenoids Removed
No
Yes
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty?
No
Yes
If patient is a girl, has menstruation begun?
No
Yes
If patient is a boy, has their voice changed or have facial hair?
No
Yes
Has the patient grown in the past year or has their shoe size changed recently?
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment?
Don't know
No
Yes