Confidential Patient Information

* First Name:
MI:
* Last Name:
Nickname:
* Birthdate:
* Gender:
Was the patient adopted?
* Address:
* City:
* State:
* Zip:
* Main Phone:
Secondary Phone:
* Email:
Social Security #:

If patient is a minor, give parent's or guardian's full name:
* Please list the names of any previous or current family members in the practice (if none, please put N/A):
List any sports, hobbies, or musical instruments played:
* How did you hear about our office?

Parent/Guardian/Responsible Party Information

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

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

Dental Insurance Information

* Policy Holder's Name:
* Relationship to Patient:
* Policy Holder's Employer:
* Insurance Company:
* Social Security #:
* Date of Birth:
* Group No.:
* Subscriber ID #:
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:
Social Security #:
Date of Birth:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:

Dental History

* Dentist Name:
* Last Dental Cleaning:
Does the patient have any dental treatment scheduled to be completed?
* What is your concern that brings you in to see us today, that you would like orthodontics to correct?
* Are you interested in:  
*Has the patient ever had an orthodontic consult or treatment?
* 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.
* Chipped permanent teeth
* Any injuries to the teeth/jaw
* Jaw Fractures, cysts, mouth infections
* Jaw clicking, popping, and/or pain
* Pain in the muscles of the face or ear
* "TMJ" (Jaw Joint) Treatments
* Periodontal/gum problems
* Periodontal treatments
* Speech problems/therapy
* Tooth grinding or clenching habit
* Aware of missing or extra permanent teeth?
* Have wisdom teeth been removed?
* Mouth breathing?
* Difficulty in chewing
* Thumb/Finger Sucking Habit
* Lip biting/sucking habit
* Nail biting habit

Medical History

Please check if the patient has had any of the following conditions either now or in the past.
* Allergic to Latex
* Nickel allergy
* Allergic to any drugs or medications
* Allergic reaction to metal snaps/buttons on clothing
* Seasonal Allergies
* Any allergies not addressed above?
* Advised to take antibiotic prophylaxis before dental appointments
* Tonsils or Adenoids Removed (Please select)
* Presently in good health:
* Birth defects or hereditary problems
* Cardiovascular Problems (Please select)
* Blood or bleeding disorder
* Bone fractures or major accidents
* Hepatitis, jaundice, or liver problems (Please select)
* High or low blood pressure (Please select)
* Diabetes
* History of Asthma
* AIDS or HIV Positive
* Sexually transmitted disease
* Mental or behavioral problems
* ADD/ADHD
* Autism spectrum
* Learning disabilities/Extra help needed with instructions
* Diagnosed with any medical conditions not addressed above?
Has puberty began (Males)
Commencement of menstruation (Females)
Currently pregnant?
Currently taking birth control medication? (Females)
* Do you currently or have you ever smoked/used tobacco products?
* Do you currently or have you ever used recreational drugs?
* Do you currently consume alcoholic beverages?
* Under a physician's non-routine care in the last 5 years?
Please list all current medications (include non-prescription):
Ahl and O'Connor Orthodontics is HIPAA compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
Signature:
Date: