Patient Biographical Information

* First Name:
Middle Initial:
* Last Name:
Nickname:
* Birthdate:
* Gender:
* Address:
* City:
* State:
* Zip:
* Home Phone:
Cell Phone: Mom
Cell Phone: Dad
Work Phone: Mom
Work Phone: Dad
Email: Mom
Email: Dad
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?

Patients Under 18

If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:

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:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:

Financial Party Information

* First Name:
Middle Initial:
* Last Name:
Relationship to Patient:
Birthdate:
* Address:
* City:
* State:
* Zip:
Do you have insurance that covers orthodontics?
If you would like us to check your benefits prior to your examination, please fill in these fields:
Insurance Company:
Member/Subscriber ID:
Group #:
Employer:
Occupation:
Work Phone #:

Dental History

Dentist Name:
Check-up Frequency:
Last Dental Visit:
* Most recent panorex taken (If none, put "None Taken")
Has the patient had an orthodontic consult or treatment?
If so, when?
What is the patients main orthodontic concern?
Please select YES or No for the Following Questions - Do Not Leave Blank
* Speech problems/therapy?
* Grind or clench teeth?
* Injury to face, jaw, teeth or mouth?
* Discomfort from teeth or gums?
* Pain, tenderness or noise in either jaw?
* Frequent headaches?
* Oral habits (thumb/finger sucking, lip/nail biting)?
* Neck/shoulder pain?
* Frequent sore throats?
* Brush teeth daily?
* Floss teeth daily?
* Mouth breathing?
* Snores during sleep?
* Any missing or extra permanent teeth?
* Apprehensive about dental care?
* Frequently Chew Gum?
* Treatment for periodontal disease
* Received TMJ Treatment
* Dry Mouth
* Family history of jaw growth problems/surgery
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
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
* Tuberculosis/Lung Disease
* Pneumonia
* Liver Disease
* Kidney Disease
* Heart Attack/Stroke
* Heart Disease
* Heart Murmur
* Congenital Heart Defect
* Requires antibiotics prior to procedures due to heart defect
* Hemophilia
* Hypertension/High Blood Pressure
* Prolonged Bleeding/Transfusion
* Anemia
* HIV/AIDS
* Hepatitis
* Tonsils/Adenoids Removed
* Cancer
* Family History of Cancer
* Received Radiation Treatment
* Growth Problems
* Endocrine Problems
* Hormone Therapy
* Latex Allergy
* Metal Allergy
* Bone Disorders/Bone Loss
* Diabetes
* Seizures/Epilepsy
* Handicaps/Disabilities
* Asthma
* Arthritis
* Ever Been Hospitalized
* Learning Disability
* Down Syndrome
* Other Genetic Condition/Syndrome
* ADHD
* Anxiety
* Depression
* Autism
Autism level: (only answer if applicable i.e. patient has autism)
* Other psychiatric problem
If any of the above medical questions were answered 'Yes', please explain: