Last Name:
First Name:
Middle:
Is this your legal name?
If not, what is your legal name?
Birthdate:
Sex:
Home Phone Number:
Cell Phone Number:
Email Address:
Street Address:
P.O. box:
City:
Province:
Postal Code:

Whom may we thank for recommending our office?
Other family members seen here:
Responsible Party:
Birthdate:
Address (if different):
Home Phone #:

Subscriber's Name:
Birthdate:
Insurance Company:
Occupation:
ID/Certificate:
Policy/Group #:
Dep #:

Subscriber's Name:
Birthdate:
Insurance Company:
Occupation:
ID/Certificate:
Policy/Group #:
Dep #:

Physician:
Dentist:
Is patient in excellent health?
Please specify:
Is patient under care of Physician?
Please specify:
Is patient currently taking medications?
Please specify:
Does patient wear contact lenses?
Please specify:

Does the patient have:
Nickel Allergy
Latex Allergy
Please specify any other allergies the patient may have:

Does the patient have a history of any of the following:
Diabetes
Epilepsy
Heart Trouble
Gland/Endocrine Problems
Rheumatic Fever
Fainting/Dizziness
Bone Disorders
Nervous Disorders
Congenital Abnormalities
Emotional Disorders
Tuberculosis
Liver Problems
Blood Disorders
Hepatitis
Anemia
Kidney Problems
Prolonged Bleeding
Frequent Sore Throats
Frequent Colds
Pneumonia
Ear Infections
Asthma
Tonsillitis
Chronic Nasal Obstruction
Tonsillectomy
HIV/AIDS
Adenoid Problems
Adenoidectomy
Trouble Sleeping
Jaw Pain/Clicking
Sleep Apnea
Other (Please Specify):
Head or Jaw Injuries
Please Specify:
Have you been informed of any missing teeth?
Previously consulted with other Orthodontist:
Had Teeth Extracted:
Received previous orthodontic treatment:
Does the patient have any history of the following:
Thumb Sucking
Finger Sucking
Lip Biting
Nail Biting
Speech Difficulty
Jaw Clenching
Tooth Grinding
Tooth Clenching
Tongue Thrusting
Mouth Breathing
Leaning on face/chin
Night Grinding
If the patient has received treatment for any of the previous, please specify:
Does the patient have regular checkups?
Date of last checkup:
Patient brushes teeth on average:
          days
Patient plays a wind instrument:
Please specify:
Patient plays sports:
Please specify:
Is patient self-conscious of teeth?
Does patient want treatment?
Reason for orthodontic consultation:
Does/has anyone else in the family have/had similar problems? Please specify: