Confidential Patient Information

* First Name:

* Last Name:

Nickname:

* Birthdate:

* Gender at birth:

* Address:

* City:

* State:

* Zip:

* Main Phone:

2nd/Cell Phone:

Email:

* Patient’s General/Pediatric Dentist:

* Whom may we thank for referring you to our practice?

* How else did you hear about our office?

Please Name:

Please list the names of any friends or family currently in the practice:

* What is the patient's main orthodontic concern?

Responsible Party Information

If the responsible financial party is someone other than the patient please provide the following:

* First Name:

* Last Name:

* Address:

* City:

* State:

* Zip:

* Phone number:

* Email address:

Medical History

Physician Name:

* Is the patient now under the care of a physician (other than routine)? If so, what is being treated? No Yes

* Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for? No Yes

List any medications currently being taken by the patient:

List any drug allergies or sensitivities that the patient may have:

Please select YES or No for the following medical conditions

Antibiotics prior to dental procedures Yes No

Congenital Heart Defects Yes No

Atrial Fibrillation Yes No

Heart Attack/Stroke Yes No

Heart Surgery/Pacemaker Yes No

Hypertension/High Blood Pressure Yes No

Hypotension/Low Blood Pressure Yes No

Heart Disease Yes No

Heart Murmur Yes No

Bleeding Disorder (anemia, sickle cell anemia, hemophilia, etc) Yes No

HIV/AIDS Yes No

Epilepsy/Seizures Yes No

Rheumatic Fever Yes No

Hepatitis/Liver Problems Yes No

Cancer/received radiation therapy Yes No

Thyroid disorder Yes No

Diabetes Yes No

Endocrine or growth problems Yes No

Bone disorders (bone loss, osteoporosis) Yes No

Tuberculosis/Lung Disease Yes No

Asthma Yes No

Kidney disease/problems Yes No

Arthritis Yes No

Fibromyalgia Yes No

Fever Blisters/Herpes Yes No

Digestive problems such as Celiac Disease, Ulcers, Crohn’s, Colitis, or Reflux Yes No

Psychiatric/Emotional Issues (depression, anxiety, etc.) Yes No

Behavioral Issues (ADHD, OCD, etc.) Yes No

If any of the above medical conditions were answered “Yes”, please explain:

If female, are you pregnant or trying to get pregnant? Yes No

Dental History

DENTAL HISTORY

TMJ HISTORY

Pain or clicking of the jaws when opening or closing Yes No

Locking of jaw Yes No

Migraines/Frequent Headaches Yes No

Use of night guard Yes No

Trauma to chin or jaws Yes No

Difficulty chewing Yes No

Clenching/Grinding Yes No

Family history of TMJ (jaw joint) problems Yes No

AIRWAY/SLEEP HISTORY

Snoring Yes No

Sleep Apnea Yes No

Bed wetting Yes No

Seasonal allergies Yes No

Removal of tonsils and/or adenoids Yes No

Mouth breathing Yes No

Sinus problems Yes No

Consultation with Ears, Nose and Throat doctor Yes No

Patients Under 18

If patient is under the age of 18, please answer the following questions:

School:

Grade:

List any sports, hobbies, or musical instruments played:

Parent/Guardian 1 Name (type N/A if adult):

Cell phone:

Parent/Guardian 2 Name (type N/A if adult):

Cell phone:

Has patient begun puberty: NoYes

If patient is a girl, has menstruation begun: NoYes

If patient is a boy, has their voice changed or have facial hair: NoYes

Has the patient grown in the past year or has their shoe size changed recently: NoYes

Patient's interest in treatment:

Has either biological parent ever had orthodontic treatment: