*Patient First Name:
MI:
*Patient Last Name:
Nickname:
*Patient Birthdate:
*Patient Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
*Email:
 
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
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?

*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
Email:
*Main Phone:
2nd/Cell Phone:
Social Security #:
Work Phone #:
Employer:
Occupation:
Length of Employment:

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

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
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.
Speech problems/therapy?
Clench or Grind Teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Pain, tenderness or noise in either jaw?
Chipped or injured permanent teeth?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Mouth breathing?
Snores during sleep?
Bleeding gums?
Other periodontal (gum) problems?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
Frequent headaches/Migraines?
If any of the above TMJ questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
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):

Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Other:
List any drug allergies or sensitivities (not listed above) 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.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia / Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Large Tonsils
Sinus trouble
Bed wetting
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid / Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems / Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Low blood pressure
Persistent cough
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:
Height:
Weight:
School:
Grade:
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:
Signature: