Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
Main Phone:
Secondary Phone:
Email:
School (if applicable):
Grade:
Please list any sports, hobbies, or musical instruments played:
What are the names of any friends or family that have been to our practice?
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:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security # (may be verified for Ins. benefits):
Address:
City:
State:
Zip:
Email:
Main Phone:
Secondary Phone:
Employer:
Position:
Work Phone:
Second Responsible Party's First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Birthdate:
Social Security Number:
Address:
City:
State:
Zip:
Email:
Main Phone:
Secondary Phone:
Employer:
Position:
Work Phone:
Dental Insurance Information
Policy Holder's Name:
Birthdate:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Work Phone:
Do you have dual dental coverage?
No
Yes
(If yes, complete information below)
Policy Holder's Name:
Birthdate:
Policy Holder's Employer:
Insurance Company Name:
Subscriber ID:
Group Number:
Insurance Company Phone:
Work Phone:
Orthodontic History
What is/are the patient's main orthodontic concern or smile goals?
Any prior orthodontic treatment? If so, where/when?
No
Yes
What is most important to you in selecting an orthodontic office?
Are you considering braces or clear aligners?
Braces
Clear Aligners
Don't Know
If patient is a minor - has either parent had orthodontic treatment?
No
Yes
If yes to previous, does either still wear a retainer?
No
Yes
Dental History
Dentist:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Last Dental Visit:
Last Dental X-rays:
How many times a day do you brush your teeth?
How often do you floss?
Periodontist:
Oral Surgeon:
Endodontist:
Does the patient need to premedicate prior to dental visit?
No
Yes
Is the patient apprehensive about dental care?
No
Yes
Does the patient have any planned or recommended dental work? If YES, please describe.
No
Yes
Have you ever had:
Oral Surgery
No
Yes
Wisdom teeth extracted
No
Yes
Your bite adjusted
No
Yes
Difficulty chewing
No
Yes
Speech issues/therapy
No
Yes
Missing or extra teeth
No
Yes
Clicking of the jaw
No
Yes
Pain in jaw
No
Yes
Periodontal treatment
No
Yes
Discomfort in teeth or gums
No
Yes
Worn a bite plane (retainer)
No
Yes
Difficulty opening/closing mouth
No
Yes
Airway/Sleep Evaluation:
Have the tonsils or adenoids been removed?
No
Yes
Do you snore or have you been told that you snore?
No
Yes
Do you have excessive daytime sleepiness?
No
Yes
Do you frequently wake up during the night?
No
Yes
Have you ever had a sleep study?
No
Yes
Do you have high blood pressure?
No
Yes
Habits:
Bite your fingernails
No
Yes
Bite your lip/cheeks regularly
No
Yes
Clench/grind your teeth
No
Yes
Mouth breathe
No
Yes
Hold foreign objects with your teeth (e.g. pencils, pipe, pins, nails)
No
Yes
Have any type of thumb or tongue habit?
No
Yes
Do you have headaches? If yes, frequency and location?
No
Yes
Have you ever had trauma or injury to the teeth or face? If yes, please describe:
No
Yes
Medical History
Physician:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Anemia
No
Yes
Arthritis
No
Yes
Asthma
No
Yes
Cancer
No
Yes
Diabetes
No
Yes
Dizziness
No
Yes
Endocrine issues
No
Yes
Epilepsy
No
Yes
Fainting
No
Yes
Head/Neck pain
No
Yes
Heart attack
No
Yes
Heart disease
No
Yes
Herpes II
No
Yes
HIV or AIDS?
No
Yes
Hypertension
No
Yes
Kidney disease
No
Yes
Liver issues
No
Yes
Prolonged bleeding
No
Yes
Rheumatic fever
No
Yes
Stroke
No
Yes
Tuberculosis
No
Yes
Venereal disease
No
Yes
FEMALES: Are You Pregnant?
No
Yes
Please list all drugs or medications currently being taken by the patient (include non-prescription):
Please list allergies or sensitivities that the patient has:
Have you ever been treated for a bone disorder or osteoporosis?
No
Yes
Have you taken (or are you taking) Bisphosphonates medications (Fosamax, Boniva)?
No
Yes
Have you had any major operations? If yes, please describe:
No
Yes
Any other medical considerations:
PLEASE SELECT EITHER FROM THE FOLLOWING two choices.
I
DO NOT
agree to the following.
I, the undersigned, have given the above dental and medical information, have reviewed it and find it accurate. If there are any changes in the information I have provided above, I will inform the practice. I authorize Dr. Andrew M. Orchin and/or Dr. Jill M. Orchin to perform an orthodontic examination and share findings with the patient's dental team and insurance as indicated. I have read the HIPAA form located on the website or reviewed the HIPAA form in the office and I give my consent.
E-Signature (Patient/Parent/Guardian):
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Date: