Confidential Patient Information

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

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

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 Visit:
Does the patient have any dental treatment scheduled to be completed?
Has the patient had an orthodontic consult or treatment?
* Does the Patient need to premedicate prior to dental visit?
* What is your main concern with the patient's teeth/smile/bite?
* Are you interested in:  

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
* Any injuries to the teeth/jaw
* Speech problems/therapy
* Tooth grinding or clenching habit
* Difficulty in chewing
* Jaw clicking, popping, and/or pain
* Lip biting/sucking habit
* Pencil/lip/nail biting habit
* Pain in the muscles of the face or ear
* Thumb/Finger Sucking Habit
* "TMJ" (Jaw Joint) Treatments
* Jaw Fractures, cysts, mouth infections
* Chipped or injured permanent teeth
* Periodontal/gum problems
* Have wisdom teeth been removed?
* Periodontal treatments
* Mouth breathing?
* Aware of missing or extra permanent teeth?
If any of the above questions were answered 'Yes', please explain:

Medical History

Please check if the patient has had any of the following conditions either now or in the past.
* Allergic to Latex
* Allergic to any drugs or medications
* Nickel allergy
* Allergic reaction to metal snaps/buttons on clothing
* 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
* Bone fractures or major accidents
* Hepatitis, jaundice, or liver problems (Please select)
* Cardiovascular Problems (Please select)
* Blood or bleeding disorder
* History of Asthma
* High or lower blood pressure (Please select)
* Diabetes
* Sexually transmitted disease
* AIDS or HIV Positive
* Mental or behavioral problems
* Learning disabilities/Extra help needed with instructions
* Autism spectrum
* ADD/ADHD
* Diagnosed with any medical conditions not addressed above?
* Was the patient adopted
Commencement of menstruation (Females) Date began:
Has puberty began (Males)
Currently taking birth control medication? (Females)
Currently pregnant? How many weeks?
* Do you currently or have you ever smoked/used tobacco products? How many per day/type?
* 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: