*First Name:
MI:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/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:
How long at this address?
Previous Address (less than 3 years)
Email:
*Main Phone:
2nd/Cell Phone:
Work Phone #:
Social Security #:
Employer:
Occupation:

Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Social Security #:
Birthdate:
Relationship to Patient:
Employer:
Occupation:
Work Phone #:
Policy Holder's Name:
Relationship to Patient:
Policy Holder's Employer:
Insurance Company:
Subscriber ID #:
Group No.:
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:
Subscriber ID #:
Group #:
Insurance Co. Address:
City:
State:
Zip:
Insurance Co. Phone No.:
Name of nearest relative not living with you:
Complete Address:
Phone:
Relationship to Patient:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
If so, when?
Does the Patient need to premedicate prior to dental visit?
What concerns you most about your smile?

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?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Presently in dental pain??
Pain, tenderness or noise in either jaw?
Frequent headaches?
Chipped or injured permanent teeth?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Brush teeth daily?
Floss teeth daily?
Snores during sleep?
Anxious about dental care?
Frequently Chew Gum?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is all dental work completed at this time?
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 been treated for "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?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

List any drug allergies or sensitivities 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 Problems
Liver Disease / Jaundice / Hepatitis
Kidney Disease
Prolonged Bleeding/Transfusion
Blood Disease
HIV/AIDS
Ear, Nose, or Throat Conditions
Tonsil or Adenoid Problem
Arthritis / Joint problems
Sinus trouble
Bed wetting
Bone fractures/trauma to face/jaw
Tired Easily
Diabetes
Lung Disease
Cancer
Thyroid / Endocrine Problems
Hormone Therapy
Metal/Aspirin/Penicillin/Acryllic Allergy
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Asthma
Sexually transmitted disease
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 acknowledge that I have received this office's privacy practices.