About You

*First Name:
MI:
*Last Name:
I Prefer to be Called:
*Gender:
*Birthdate:
Age:
Social Security #:
*Address:
*City:
*State:
*Zip:
Email:
Marital Status:
*Home Phone #:
Cell Phone #:
Work Phone #:
Employer:
How long there?
Occupation:
Whom may we thank for referring you?
Other family members seen by us:

Spouse Information

Name:
Birthdate:
Age:
Employer:
Cell Phone #:
Work Phone:
Relation:

Orthodontic Insurance

Primary Coverage

Orthodontic Coverage?
Dental Coverage?
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Group # (Plan, Local or Policy#):
Insured's Name:
Relation:
Birthdate:
Insured's ID #:
Insured's Social Security #:
Policy Holder's Employer:

Secondary Coverage

Orthodontic Coverage?
Dental Coverage?
Insurance Co. Name:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Group # (Plan, Local or Policy#):
Insured's Name:
Relation:
Birthdate:
Insured's ID #:
Insured's Social Security #:
Policy Holder's Employer:

Person Responsible for Account

*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*State:
*Zip:
*Best Contact Number:
Relationship to Patient:

Emergency Information

Emergency Contact Name:
Phone:
Relationship to Patient:

Medical History

Your current health is:
Do you have a personal physician?
Physician Name:
Date of Last Physical:
Phone Number:

Are you currently under the care of a physician?
If yes, please explain:
Do you smoke or use tobacco in any other form?
If yes, please explain:
Have you had any metal rods, pins or implants?
If yes, please explain:
Are you taking any prescription/over the counter drugs?
List any medications currently being taken by the patient (include non-prescription):
Have you ever taken Phen-Fen? (Also known as Redux or Pondimin)
If yes, please explain:
Have you ever taken Fosamax, or any other bisphosphonate?
If yes, please explain:
For Women
Are you using a prescribed method of birth control?
Are you pregnant?
Week #
Are you nursing?
Have you ever had any of the following diseases or medical problems Cannot be blank.
Abnormal bleeding?
Hepatitis
Hypertension/High Blood Pressure
Low blood pressure
Anemia / Blood disorder
Artificial Bones/Joints/Valves
HIV/AIDS
Hospitalized for any reason
Diabetes
Asthma
Arthritis / Joint problems
Blood Transfusion
Kidney Problems
Psychiatric Problems
Cancer/Chemotherapy
Sickle Cell Disease/Traits
Drug/Alcohol Abuse
Valve Prolapse
Difficulty Breathing/Snoring?
Ulcers
Radiation Treatment
Heart Attack/Stroke
Rheumatic/Scarlet
Shingles
Emphysema
Hemophilia
Severe/Frequent headaches?
Glaucoma
Epilepsy / Seizures / Fainting
Tuberculosis
Heart Murmur
Heart Surgery/Pacemaker
Colitis
Venereal Disease
If any of the above medical questions were answered 'Yes' , please explain:
Are You Allergic to any of the Following?
Asprin
Penicillin
Codeine
Latex
Tetracycline
Anesthetics
Please list any other drug allergies or sensitivities (not listed above) that the patient may have:

Dental Health

What are the main concerns you would like orthodontic treatment to accomplish?
Have you ever been evaluated for orthodontic treatment?
Have you ever had a serious/difficult problem associated with any previous dental work?
Do you now or have ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Your current dental health is:
Have you ever had an:
Do you have any speech problems?
Do you generally breathe through your mouth?
If yes, do you breathe through your mouth:
Any missing or extra permanent teeth?
Are you happy with the way your smile looks?
If not, what would you change?