Confidential Patient Information

* First Name:
* Last Name:
* Birthdate:
* Gender at birth:
* Address:
* City:
* State:
* Zip:
* Main Phone:
2nd/Cell Phone:

* 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?
* 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:
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
Congenital Heart Defects
Atrial Fibrillation
Heart Attack/Stroke
Heart Surgery/Pacemaker
Hypertension/High Blood Pressure
Hypotension/Low Blood Pressure
Heart Disease
Heart Murmur
Bleeding Disorder (anemia, sickle cell anemia, hemophilia, etc)
Rheumatic Fever
Hepatitis/Liver Problems
Cancer/received radiation therapy
Thyroid disorder
Endocrine or growth problems
Bone disorders (bone loss, osteoporosis)
Tuberculosis/Lung Disease
Kidney disease/problems
Fever Blisters/Herpes
Digestive problems such as Celiac Disease, Ulcers, Crohn’s, Colitis, or Reflux
Psychiatric/Emotional Issues (depression, anxiety, etc.)
Behavioral Issues (ADHD, OCD, etc.)
If any of the above medical conditions were answered “Yes”, please explain:
If female, are you pregnant or trying to get pregnant?

Dental History

Missing teeth
Extra teeth
Impacted teeth
Trauma to teeth
Extraction of primary or permanent teeth
Tooth pain/sensitivity
Periodontal surgery
Speech Issues/Therapy
Thumb/finger sucking
Tongue thrust
Do you have any relevant dental history you would like to share?
Previous Orthodontic Treatment or Consultation:
Pain or clicking of the jaws when opening or closing
Locking of jaw
Migraines/Frequent Headaches
Use of night guard
Trauma to chin or jaws
Difficulty chewing
Family history of TMJ (jaw joint) problems
Sleep Apnea
Bed wetting
Seasonal allergies
Removal of tonsils and/or adenoids
Mouth breathing
Sinus problems
Consultation with Ears, Nose and Throat doctor

Patients Under 18

If patient is under the age of 18, please answer the following questions:
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:
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:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment: