Confidential Patient Information
*
First Name:
MI:
*
Last Name:
Nickname:
*
Birthdate:
*
Gender:
Male
Female
Was the patient adopted?
Yes
No
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
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
Check if the patient is also the responsible party. Responsible party must be at least 18 years old.
*
First Name:
Middle Initial:
*
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*
Birthdate:
*
Address:
*
City:
*
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
*
Zip:
Email:
*
Main Phone:
2nd/Cell Phone:
Work Phone #:
*
Social Security #:
*
Employer:
*
Occupation:
Length of Employment:
First Name:
Middle Initial:
Last Name:
Marital Status:
Single
Married
Partnered
Widowed
Divorced
Seperated
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TX
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Email:
Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:
Dental Insurance Information
Do you have dental insurance?
Check if the Responsible Party is also the dental insurance policy holder.
*
Policy Holder's Name:
*
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
*
Policy Holder's Employer:
*
Insurance Company:
*
Social Security #:
*
Date of Birth:
*
Group No.:
*
Subscriber ID #:
Insurance Co. Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TC
UT
VT
VA
WA
WV
WI
WY
Zip:
Insurance Co. Phone No.:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's Employer:
Insurance Company:
Social Security #:
Date of Birth:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip:
Insurance Co. Phone No.:
Dental History
*
Dentist Name:
*
Last Dental Cleaning:
Does the patient have any dental treatment scheduled to be completed?
No
Yes
*
What is your concern that brings you in to see us today, that you would like orthodontics to correct?
*
Are you interested in:
Metal Braces
Clear Braces
Invisalign
Other/Not Sure
*
Has the patient ever had an orthodontic consult or treatment?
No
Yes
*
Does the Patient need to premedicate prior to dental visit?
No
Yes
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
No
Yes
*
Any injuries to the teeth/jaw
No
Yes
*
Jaw Fractures, cysts, mouth infections
No
Yes
*
Jaw clicking, popping, and/or pain
No
Yes
*
Pain in the muscles of the face or ear
No
Yes
*
"TMJ" (Jaw Joint) Treatments
No
Yes
*
Periodontal/gum problems
No
Yes
*
Periodontal treatments
No
Yes
*
Speech problems/therapy
No
Yes
*
Tooth grinding or clenching habit
No
Yes
*
Aware of missing or extra permanent teeth?
No
Yes
*
Have wisdom teeth been removed?
No
Yes
*
Mouth breathing?
No
Yes
*
Difficulty in chewing
No
Yes
*
Thumb/Finger Sucking Habit
No
Yes
*
Lip biting/sucking habit
No
Yes
*
Nail biting habit
No
Yes
Medical History
Please check if the patient has had any of the following conditions either now or in the past.
*
Allergic to Latex
No
Yes
*
Nickel allergy
No
Yes
*
Allergic to any drugs or medications
No
Yes
*
Allergic reaction to metal snaps/buttons on clothing
No
Yes
*
Seasonal Allergies
No
Yes
*
Any allergies not addressed above?
No
Yes
*
Advised to take antibiotic prophylaxis before dental appointments
No
Yes
*
Tonsils or Adenoids Removed (Please select)
No
Yes
Tonsils
Adenoids
*
Presently in good health:
No
Yes
*
Birth defects or hereditary problems
No
Yes
*
Cardiovascular Problems (Please select)
No
Yes
Heart Murmur
Heart Attack
Angina
Heart Defect
*
Blood or bleeding disorder
No
Yes
*
Bone fractures or major accidents
No
Yes
*
Hepatitis, jaundice, or liver problems (Please select)
No
Yes
Hepatitis
Jaundice
Liver Problems
*
High or low blood pressure (Please select)
No
Yes
High Blood Pressure
Low Blood Pressure
*
Diabetes
No
Yes
*
History of Asthma
No
Yes
*
AIDS or HIV Positive
No
Yes
*
Sexually transmitted disease
No
Yes
*
Mental or behavioral problems
No
Yes
*
ADD/ADHD
No
Yes
*
Autism spectrum
No
Yes
*
Learning disabilities/Extra help needed with instructions
No
Yes
*
Diagnosed with any medical conditions not addressed above?
No
Yes
Has puberty began (Males)
No
Yes
Commencement of menstruation (Females)
No
Yes
Currently pregnant?
No
Yes
Currently taking birth control medication? (Females)
No
Yes
*
Do you currently or have you ever smoked/used tobacco products?
No
Yes
*
Do you currently or have you ever used recreational drugs?
No
Yes
*
Do you currently consume alcoholic beverages?
Never
Infrequent
Occasional
Daily
*
Under a physician's non-routine care in the last 5 years?
No
Yes
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.
I understand the information that I have provided is correct to the best of my knowledge, that it will be in the strictest confidences, and that it is my responsibility to inform this office of any changes to my medical status. I hereby authorize the release of any information related to insurance claims. I authorize payment of any insurance benefits to the office. I consent to the examination by the doctor and the dental staff to perform any necessary dental services I may need.
We are committed to providing high quality care to our patients. The use of photography and audio/video recording may be used for training purposes, quality control, and/or marketing. I grant Ahl and O'Connor Orthodontics, LLC the right to edit, use and reuse said products for use in print, on the internet, and all other forms of social media. I also hereby release Ahl and O'Connor Orthodontics, LLC and its agents and employees from all claims, demands, and liability whatsoever in connection with the above. I understand no royalty, fee, or other compensation shall become payable to me by reason of such use. I consent to and understand the the photograhps and audio/video recordings may be taken at the practice of Ahl and O'Connor Orthodontics, LLC.
Signature:
Date: