Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Address:
City:
State:
Zip:
Main Phone:
2nd/Cell Phone:
Email:
Social Security #:
Please list the names of any friends or family currently in the practice:
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
Parents
Self
Spouse
Step Father
Step Mother
Other
Email:
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?
No
Yes
If so, please name the Insurance Company:
Subscriber ID #:
Policy Holder's Name:
Policy Holder's Birthdate:
Dental History
Dentist Name:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
Grind or clench 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
Fluoride treatments?
No
Yes
Requires premedication?
No
Yes
Apprehensive about dental care?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Patient Health:
Good
Excellent
Fair
Poor
Address:
City:
State:
Zip:
Has the patient had a physical within the past 12 months?
No
Yes
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES or No for the Following Questions - Do Not Leave Blank
Rheumatic Fever
No
Yes
Tuberculosis/Lung Disease
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
Tonsils/Adenoids Removed
No
Yes
Cancer
No
Yes
Diagnosed Sleep Apnea
No
Yes
Received Radiation Treatment
No
Yes
Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Latex/Metal Allergy
No
Yes
Bone Disorders/Bone Loss
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Asthma
No
Yes
Arthritis
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Airway Assessment
Snoring?
Do you
Snore Loudly
(loud enough to be heard through closed doors or your bed-partner elbows you for snoring at night)?
No
Yes
Tired?
Do you often feel
Tired, Fatigued, or Sleepy
during the daytime (such as falling asleep during driving or talking to someone)?
No
Yes
Observed?
Has anyone
Observed
you
Stop Breathing
or
Choking/Gasping
during your sleep?
No
Yes
Pressure?
Do you have or are you being treated for
High Blood Pressure
?
No
Yes
Height:
Weight:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
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
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative