Patient Information Form
Patient Name
*
First Name
Last Name
Nickname
SSN
Sex
Male
Female
Prefer not to say
Preferred Pronouns
She/Her
He/Him
They/Them
Prefer not to say
Birithdate
-
Month
-
Day
Year
Date
Age
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
School (If student)
Grade (If student)
Employed By/Occupation
Referred By
Marital Status
Single
Married
Separated
Divorced
Widowed
Name of General Dentist
Date of Last Visit
-
Month
-
Day
Year
Date
Related Patients That Are or Have Been Under Our Care
Names and Ages of Other Children
Does the Patient Have Orthodontic Insurance?
*
Yes
No
Patient's Interests and Activities
Parent Information 2
(If patient is a minor)
Parent's Name
First Name
Last Name
Preferred Pronouns
She/Her
He/Him
They/Them
Prefer not to say
Marital Status
Single
Married
Separated
Divorced
Widowed
Phone Number
Please enter a valid phone number.
Email
example@example.com
SSN
Occupation/Employed By
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Information 1
(If patient is a minor)
Parent's Name
First Name
Last Name
Preferred Pronouns
She/Her
He/Him
They/Them
Prefer not to say
Marital Status
Single
Married
Separated
Divorced
Widowed
Phone Number
Please enter a valid phone number.
Email
example@example.com
SSN
Occupation/Employed By
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Type a question
*
Joint swelling
Bone disorders
Heart trouble
Heart Murmur
Mitral valve prolapse
Rheumatic fever
Thyroid problems
Diabetes
Hepatitis
Nervous disorders
Brain injury
Tuberculosis
Anemia
Asthma
Epilepsy
Arthritis
High Blood Pressure
Prolonged bleeding
Faintness/Dizziness
Tonsils removed
Adenoids removed
Sore throats
Tonsillitis
Earaches
None
Has patient ever been hospitalized?
*
Yes
No
If YES, for what reason?
Is patient under physician's care presently?
*
Yes
No
If YES, for what reason?
Name of physician
List any serious illnesses
List any allergies
List drugs or medications now being taken
Females: Has menstruation begun?
Yes
No
Date (Month/Year)
Dental History
Any injuries to:
*
Face
Mouth
Teeth
None
Does patient have a habit of:
*
Thumb Sucking
Finger Sucking
Lip Sucking
None
Any missing teeth?
*
Yes
No
Any speech problems?
*
Yes
No
Any difficulty in swallowing or chewing?
*
Yes
No
Any pain or clicking on opening mouth?
*
Yes
No
Does patient visit dentist regularly?
*
Yes
No
Does patient snore?
*
Yes
No
Does patient have sleep apnea?
*
Yes
No
Does patient use a CPAP?
*
Yes
No
Has an orthodontist been consulted previously?
*
Yes
No
If yes, reason:
Does patient use tobacco?
Smoking
Vaping
Smokeless Tobacco
N/A
What is your reason for seeking orthodontic treatment?
Patient's attitude toward orthodontic treatment:
Very motivated
Will cooperate if needed
Not motivated
Is patient adopted?
Yes
No
If yes, at what age?
Any other information that would be helpful to us:
Signature
Signature of Patient or of Parent/Guardian if Patient is a Minor
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: