Confidential Patient Information

*First Name:
Middle Initial:
*Last Name:
Prefers to be called:
*Birthdate:
SS#:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell Phone:
Email Address:
Sports/Hobbies/Instruments Played:
Employer:
Occupation:
*Whom may we thank for referring you or how did you hear about our office?

Emergency Contact

*Name of closest relative:
*Relation to you:
*Phone:

Dental Insurance Information

Insurance Company Name (with state if applicable):
Customer Service Phone Number:
Subscriber Name:
Subscriber ID #:
Subscriber Birthdate:

Dental History

*Have you ever been to an orthodontist before?
What is your primary orthodontic concern?
Dentist Name:
Dentist Phone #:
Approximate date of last visit:
 
Address:
City:
State:
Zip:
Please select YES or No for the Following Questions - Do Not Leave Blank
Permanent teeth removed
Supernumerary (extra) or congenitally missing teeth
Chipped or otherwise injured primary (baby) or permanent teeth?
Jaw fractures, cysts, or mouth infections
Periodontal (gum) Problems?
Food impaction between teeth
"Gum Boils", frequent canker or cold sores
Thumb, finger, or sucking habit
Mouth breathing habit, snoring or difficulty in breathing
Tooth grinding or jaw clenching
Any pain, clicking, or locking of jaw
Any trauma to the face, teeth, or jaws
Any pain or soreness in the muscles of the face or around the ears
Difficulty chewing or jaw opening
TMD or TMJ problems
Any teeth irritating cheek, lip, tongue or palate
Aware of over or under developed jaw
Any wisdom teeth problems
Had periodontal (gum) treatment
Trouble associated with any previous dental treatment
Ever had a prior orthodontic examination or treatment
Do you object to wearing orthodontic appliances (braces) should they be indicated
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Please select YES or No for the Following Questions - Do Not Leave Blank
Birth defects or hereditary problems
Bone fractures or any major accidents
Rheumatoid or arthritic conditions
Endocrine or thyroid problems
Kidney problems
Cancer, tumor, radiation treatment, or chemotherapy
Hyperacidity or reflux
AIDS or HIV positive
Hepatitis, jaundice, or liver problems
Fainting spells, seizures, epilepsy, or neurological problems
Mental health disturbance or depression
Vision, hearing, tasting, or speech difficulties
History of eating disorder
Excessive bleeding, bruising tendency, anemia, or bleeding disorder
High or low blood pressure
Chest pain, shortness of breath or swelling ankles
Cardiovascular problems
Eye, ear, nose, or throat condition
Hayfever, sinus trouble, or hives
Asthma
Tonsil or adenoid conditions
Osteoporosis
Current or past substance abuse
Chew or smoke tobacco
Hospitalizations/operations
Women: Pregnant or anticipating becoming pregnant
If any of the above medical questions were answered 'Yes' , please explain:
Please describe any medical conditions we have not discussed above that you feel we should be aware of
Are you taking any medications, nutrient supplements, herbal medications or non prescription medicine? If yes, please name them and what they are taken for.
Check the box if you currently have or have ever had an allergic reaction to the following:
Foods (specify)
Please list any other allergies
Physician Name:
Date of last Physical:
Phone:

Patients Under 18


If patient is under the age of 18, please answer the following questions:
What school does child attend?
Grade:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
Please list the name and birthdate of any siblings:
Parent/Guardian 1 Information:
First Name:
Last Name:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Birthdate:
Employer:
Job Title:
Parent/Guardian 2 Information:
First Name:
Last Name:
Social Security #:
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Birthdate:
Employer:
Job Title: