Patient Information
Name
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Preferred Name
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Sex
Please Select
Male
Female
N/A
Age
Phone Number:
Grade
Dentist
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Physician
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
What is the reason for seeking orthodontic treatment?
Have you seen other orthodontists concerning the problem in the past?
Yes
No
Does anyone in your family have a similar dental problem?
Yes
No
Has anyone in your family had orthodontic treatment?
Yes
No
Whom may we thank for referring you to our office?
Please list any special interests (hobbies, sports, pasttimes, etc)
Responsible Party
Father's Name
First Name
Last Name
SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Employer
Occupation
No. of Years
Mother's Name
First Name
Last Name
SSN
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Work Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Employer
Occupation
No. of Years
Person Responsible for Account
Billing Address (if different from above)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Method of Contact
Phone
Email
Phone Number
Please enter a valid phone number.
Email
example@example.com
Patient lives with:
Both parents
Mother
Father
Other
Number of Brothers
Ages
Number of Sisters
Ages
Policy Holder's Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Insurance ID #
Insurance Company
Group ID
Phone Number
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have dual coverage?
Yes
No
Policy Holder's Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Insurance ID #
Insurance Company
Group ID
Phone Number
Please enter a valid phone number.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that where appropriate credit bureau reports may be obtained
Last Date of Physical Examination
-
Month
-
Day
Year
Date
Is the patient under a physician's care?
Yes
No
If so, why?
Is the patient taking any medication?
Yes
No
If so, for what?
Has the patient been treated for any of the following?
Yes
No
Diabetes
Pneumonia
Heart Problems
Rhuematic Fever
Bone Disorders
Hepatitis
Attention Deficit Disorder
AIDS or HIV+
Tuberculosis
Anemia
Epilepsy
Asthma
Kidney Problems
Thyroid Problems
Endocrine Problems
Prolonged Bleeding
Liver Problems
Fainting or Dizziness
Mental Illness
Depression
Does the patient often have:
Colds
Sore Throats
Ear Infections
Does the patient have trouble breathing through his/her nose?
Yes
No
Have the tonsils or adenoids been removed?
Yes
No
Is so, when?
Please list any allergies or drug sensitivities
Please describe any past or present medical problems, hospitalizations or operations
Does the patient have any special conditions not mentioned above?
When did the patient last visit his/her dentist?
Were x-rays taken?
Have there been any injuries to the face, mouth, or teeth?
Yes
No
Please explain
Has the patient had any teeth (baby or permanent) removed by a dentist?
Yes
No
Did the patient ever suck his/her thumb?
Yes
No
Did the patient ever suck his/her thumb?
Yes
No
If so, to what age?
Does the patient have any of the following habits?
Lip biting
Pencil biting
Fingernail biting
Other
Has the patient had
Speech therapy
Tongue thrust therapy
Does the patient have any speech problems at the present time?
Yes
No
Are the patient's teeth or gums sensitive?
Yes
No
Do his/her gums bleed easily?
Yes
No
Does the patient have pain or difficulty when chewing, talking, or using his/her jaw?
Yes
No
Does the patient have pain in or about the jaws,ears,temples, or cheeks?
Yes
No
Does the patient have frequent headaches? (more than 1 per week)?
Yes
No
Does the patient's jaw "catch or lock" when opening wide, for instance yawning?
Yes
No
Is the patient aware of noises in his/her jaw joints?
Yes
No
Has the patient's bite felt uncomfortable or unusual?
Yes
No
Are you aware of the patient clenching or grinding during the day or night?
Yes
No
Has the patient been previously treated for a jaw joint problem?
Yes
No
If so when?
Does the patient have arthritis?
Yes
No
Has the patient had a recent injury to his/her jaw,head or neck?
Yes
No
Submit
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