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 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?

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 Visit:
Does the patient have any dental treatment scheduled to be completed?
* What is your main concern with the patient's teeth/smile/bite?
* 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.
* 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
* Pain in the muscles of the face or ear
* Pencil/lip/nail biting habit
* "TMJ" (Jaw Joint) Treatments
* Thumb/Finger Sucking Habit
* 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?

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?
* Tonsils or Adenoids Removed (Please select)
* Presently in good health:
* Advised to take antibiotic prophylaxis before dental appointments
* Blood or bleeding disorder
* Birth defects or hereditary problems
* Bone fractures or major accidents
* Cardiovascular Problems (Please select)
* Hepatitis, jaundice, or liver problems (Please select)
* History of Asthma
* High or low blood pressure (Please select)
* Diabetes
* Sexually transmitted disease
* AIDS or HIV Positive
* Mental or behavioral problems
* Learning disabilities/Extra help needed with instructions
* ADD/ADHD
* Autism spectrum
* Diagnosed with any medical conditions not addressed above?
Has puberty began (Males)
Commencement of menstruation (Females)
Currently taking birth control medication? (Females)
Currently pregnant?
* 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: