*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Cell Phone:
Home Phone:
*Email:

Whom may we thank for referring you to our practice?
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
If patient is a minor, give parent's or guardian's name:
If patient is a minor, parents are:
If patient is a minor, who does the patient live with?
If the patient is a minor, I consent for Wang Orthodontics to disclose protected health information regarding this patient to the following authorized parties (this allows other family members to obtain information about the patient’s treatment or schedule appointments for the patient)
*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
Email:
*Cell Phone:
Home Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Employer:
Occupation:
Work Phone #:
Relationship to Patient:
Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group No.:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Birthdate:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Policy Holder's Employer:
Relationship to Patient:
Has the patient had a previous orthodontic consult or treatment?
If so, when and where?
What is the patient's main orthodontic problem as you see it?
Indicate your concern for correcting the problem:
Does anyone in the family have similar dental or facial conditions? Who?
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Is all dental work completed at this time?
Does the Patient need to premedicate prior to dental visit?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Oral habits (thumb/finger sucking, lip/nail biting)?
Tonsils or Adenoids removed?
Frequent headaches or jaw pains?
Frequent nasal obstruction earaches, or sore throats?
Accidents or trauma to face or teeth?
Apprehensive about dental care?
Speech/Hearing Difficulties?
Clench or Grind Teeth?
Discomfort from teeth or gums?
Mouth breathing?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

List any drug or environmental 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.
Rheumatic Fever or Rheumatic heart disease
Heart Problems
Pneumonia or Lung Disease
Kidney Disease or Diabetes
Hypertension/High Blood Pressure
Anemia, Hemophilia, or Prolonged Bleeding
Hepatitis/Tuberculosis/HIV/AIDS
Prosthetic joints
Cancer
Received Radiation Treatment
Nervous Disorders
Seizures / Epilepsy
Emotional/Learning Problems
Asthma
Handicaps/Disabilities
Does patient use tobacco products?
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
School:
Grade:
Indicate the child's level of concern for correcting the orthodontic problem:
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:
Has either biological parent ever had orthodontic treatment:
Name of orthodontist: