Patient Biographical Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Email:
Social Security #:
Allow us to communicate with you via text?
(Standard data rates may apply)
No
Yes
Please list the names of any friends or family currently in the practice:
What are the patient's interests (i.e. sports, hobbies, or musical instruments)?
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
Main Phone:
Cell Phone:
Social Security Number:
Allow us to communicate with you via text?
(Standard data rates may apply)
No
Yes
Spouse or Other Parent's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Employer:
Occupation:
Length of Employment:
Work Phone:
Dental Insurance Information
Insurance Company Name:
Insurance Company Phone:
Policy Holder's Employer:
Policy Holder's Name:
Subscriber ID or SSN:
Policy Holder's Birthdate:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Insurance Company Name:
Insurance Company Phone:
Policy Holder's Employer:
Policy Holder's Name:
Subscriber ID or SSN:
Policy Holder's Birthdate:
Dental History
Dentist Name:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consult or treatment?
No
Yes
If so, when?
What is the patient's main orthodontic concern?
Interested in braces or Invisalign treatment?
Braces
Invisalign
Both/No Preference
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 or therapy?
No
Yes
Clench or grind teeth?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Oral habits (thumb or finger sucking, lip or nail biting)?
No
Yes
Neck or shoulder pain?
No
Yes
Frequent sore throats?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently chew gum?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Is all dental work completed at this time?
(If No, please explain:)
No
Yes
Please select 'Yes' if the patient has had any of the TMJ conditions listed below either now or in the past. Cannot be blank.
Have you had a TMJ screening?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you notice clicking or popping in your jaw joint?
No
Yes
Has your jaw ever locked?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Does your bite feel uncomfortable or unusual?
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
Please check any of the following which the patient has had or presently has.
Abnormal bleeding/Hemophilia
Allergies/Hives
Angina Pectoris
Anemia or blood disorder
Arthritis or joint problems
Artifical joint
Asthma
Bed wetting
Bisphosphonates (Fosamax, Boniva)
Blood transfusion
Bone disorders or loss
Bone fractures/trauma to face/jaw
Cancer
Cold sores
Chronic fatigue
Cortisone medication
Diabetes
Emphysema
Treated for emotional problems
Fainting/dizzy spells
Genital Herpes
Glaucoma
Growth problems
Hay fever
Heart attack or stroke
Heart defect (congenital)
Heart disease
Heart murmur
Heart pacemaker
Heart surgery
Heart valves damaged/artificial
High blood pressure
HIV/AIDS
Hormone therapy
Kidney disease
Liver disease/Jaundice/Hepatitis
Low blood pressure
Nervous disorders
Persistent cough
Pneumonia
Rheumatic fever
Scarlet fever
Seizures/Epilepsy
Sexually transmitted disease
Sinus trouble
Stomach ulcers/Hyperacidity
Substance abuse problem
Thyroid/Endocrine problems
Tonsils enlarged
Tonsils/Adenoids removed
Tuberculosis (TB)
Does the patient have any disease(s) or condition(s) NOT listed above? If yes, please list:
Has the patient been hospitalized during the past two years. If yes, please explain:
No
Yes
Has the patient been under a physician's care in the last two years for a specific illness/condition? If yes, please explain:
No
Yes
Has the patient taken any medications in the last two years? If yes, please list:
No
Yes
Please select any of the allergies or drug reactions that the patient has:
Latex
Nickel/Metal
Sulfa drugs
Penicillin
Aspirin/Ibuprofen
Tylenol
Local anesthetics
Codeine or other narcotics
Other allergy (not listed above):
Female patient ONLY: Are You Pregnant?
No
Yes
Patients Under 18
If patient is under the age of 18, please answer the following questions:
What is the patient's attitude toward braces?
Eager
Willing
Indifferent
Resigned
Opposed
MALE PATIENTS: Has his voice begun to change?
No
Yes
Has he started to shave?
No
Yes
FEMALE PATIENTS: Has she started her monthly period?
No
Yes
If so, when?
Has the patient grown A LOT in the past year or has their shoe size changed recently?
No
Yes
Father's Height:
Mother's Height:
Patient's Height:
If patient has sibling(s), siblings' ages and heights:
Name:
DOB:
Age:
Height:
Name:
DOB:
Age:
Height:
Name:
DOB:
Age:
Height:
I certify that to the best of my knowledge, these answers are true and correct. 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 at my next appointment.
I understand that where appropriate, credit bureau reports may be obtained.
Make sure you have answered all required questions labeled with
*
before submitting the form.