*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Home Phone:
Cell Phone:
Email:
Social Security #:

If patient is a minor, give parent's or guardian's name:
If patient is a minor, who does the patient live with?
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?

*First Name:
Middle Initial:
*Last Name:
Marital Status:
Relationship to Patient:
*Birthdate:
*Address:
*City:
*State:
*Zip:
Years at this address?
Previous Address (If less than 3 years)
Email:
*Home Phone:
Cell Phone:
Work Phone:
Social Security #:
Employer:
Occupation:
Length of Employment:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Relationship to Patient:
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone:
Do you have dual dental coverage?
  (If yes, complete information below)

Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Is there any dental work that still needs to be completed?
If yes, please explain:
Has the patient ever had an orthodontic consult or treatment?
If so, when?
How many times per day does the patient brush their teeth?
How many times per week does the patient floss their teeth?
How many times per week does the patient use mouthwash?
Does the patient need antibiotic premedication prior to dental treatment?
Has the patient ever used alcohol?
If yes, please describe type, frequency, and amount.
Has the patient ever used tobacco?
If yes, please describe type, frequency, and amount.
Has the patient ever used illicit drugs?
If yes, please describe type, frequency, and amount.
What is the patient's main orthodontic concern?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Clench or grind teeth?
Thumb/finger sucking?
Lip/nail biting?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness, or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste/mouth odor?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently chew gum?
Jaw fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you ever been treated for TMD ("TMJ")?
Do you notice clicking or popping in your jaw joint?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
Physician Name:
Date of Last Physical:
Patient Health:
Address:
City:
State:
Zip:

Has there been any change in the patient's general health within the last year?
If yes, please explain:
Is the patient currently under the care of a physician (other than routine)?
If yes, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years?   
If yes, what for?
List any medications currently being taken by the patient (include non-prescription):

Does the patient have any allergies or drug reaction to:
Latex
Penicillin
Other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Other:
Please explain all "Yes" answers and list any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Damaged or Artificial Heart Valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease/Jaundice/Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Low Blood Pressure
Prolonged Bleeding/Transfusion
Anemia/Blood Disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis/Joint Problems
Large Tonsils
Sinus Trouble
Bed Wetting
Substance Abuse Problem (past or present)
Bone Fractures/Trauma to Face/Jaw
Prosthetic Joints
Chronic Fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer (Patient himself/herself)
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis/Atherosclerosis
Thyroid/Endocrine Problems
Stomach Ulcer or Hyperacidity
Hormone Therapy
Metal Allergy
Nervous System Disorders
Bone Disorders/Bone Loss
Seizures/Epilepsy/Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory Problems/Emphysema
Persistent Swollen Neck Glands
Sexually Transmitted Disease
Persistent Cough
FEMALES: Are you pregnant?
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes', please explain:
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
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:
Has either biological parent ever had orthodontic treatment:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice. 
I understand that where appropriate, credit bureau reports may be obtained.