Date_____________
PATIENT INFORMATION
Patient’s Full name_________________________________________ Date of Birth_______________ Age_________ Sex_______
Address____________________________________________City/State___________________________Zip Code______________
Home Phone _________________________ Cell Phone _________________________ Work Phone ________________________ _
SSN______-_____-_______ Email___________________________________________
Names of friends of relative who were former patients_______________________________________________________________
Who may we thank for referring you to our office? __________________________________________________________________
Patient’s Dentist_____________________________________ Patient’s Physician_________________________________________
INSURANCE INFORMATION
Do you have Orthodontic Insurance?
YES
NO
If yes, please complete the following:
Insured’s Name_______________________________ Date of Birth________________ Insured’s Social Security #____-___-_____
Insurance Company___________________________________ Group #___________________ Local #_______________________
Insurance Company Address___________________________________________________________________________________
Insurance Company Phone #______________________________Insured’s Employer_____________________________________
Do you have dual coverage?
YES
NO
If yes, please complete the following:
Insured’s Name_____________________________________ Date of Birth____________ Insured’s Social Security #____-___-_____
Insurance Company__________________________________ Group #___________________ Local #_________________________
Insurance Company Address____________________________________________________________________________________
Insurance Company Phone #________________________________Insured’s Employer____________________________________
DENTAL HISTORY
Does patient receive regular dental checkups?
YES
NO
Last dental exam__________________________________ Last Dental X-rays___________________________________________
Has patient received any previous orthodontic consultation or treatment? ______________________________________________
How often does patient brush his/her teeth? ____________________ Is floss used?________________ How often? _____________
Does the patient currently have, or has the patient ever had any of the following?
Y
N
Periodontal disease
Y
N
Gum surgery
Y
N
Root canals, crowns or bridges
Y
N
Any clicking, popping or pain of jaw, joints (TMJ)
Y
N
Any missing or extra teeth
Y
N
Trouble chewing
Y
N
Any past facial or mouth injuries? What? ____________________________________________________
What are you or your dentist most concerned about? (Purpose of visit)__________________________________________________
ORAL HISTORY
The following are some habits commonly found which may influence tooth position. Last info as pertains to patient:
Y
N
Thumb sucking/until age________
Y
N
Finger sucking/ until age_________
Y
N
Nail biting
Y
N
Mouth Breather
Y
N
Grinding of Teeth
Other habits________________________________________________________________________________________________
Has patient ever had any speech therapy? ________________________________________________________________________
List any musical instruments played_____________________________________________________________________________
HEALTH HISTORY
Has patient been under the care of a physician during the past two years? (Other than routine checks)
Y
N
If yes, for what? ______________________________________________________________________________________________
Is patient currently taking medications? ___________________________________________________________________________
Is patient allergic to anything (drugs, food, pollen, etc.)_______________________________________________________________
Does the patient currently have, or has the patient ever had any of the following?
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Tonsils Removed
Adenoids removed
Heart problems
Diabetes
Anemia
Pneumonia
Hepatitis
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Epilepsy/Seizures
Asthma
Bleeding problems
High Blood Pressure
Immune Disorders
Lung Problems
Tuberculosis
Have you been diagnosed or treated for osteoporosis?
If yes, have you ever taken or are you currently taking (circle):
Fosamax
Didronel
Boniva
Y
Actonel
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Nasal airway problems
Sinus problems
Speech problems
Arthritis
Tobacco usage
Respiratory problems
N
Reclast
or a generic form of Bisphophonates
Does the patient have any special problems not listed above? ________________________________________________________
EMERGENCY INFORMATION
Name of emergency contact person______________________________________________________________________________
Relation_________________________________ Phone #____________________________________
Our Policy is to have an appointment reminder for every patient for every appointment. Please let us know which method of
contact you prefer to receive your reminder and fill in the appropriate information.
Phone Call/Voicemail
______-______-_________
Text
______-______-_________
Email
__________________________________________________________________