PATIENT INFORMATION


Patients Name Last
First
Middle

Address
Street

City
State
Zip

Phone Date of Birth

Age

 S.S.N. Gender

Referred by:
Dentist:  Physician:  Oral Surgeon:

School Grade

Siblings / Children     (Names and birthdates please)
If patient is a minor, give parent's or guardian's name.
How did you hear about our office? 

RESPONSIBLE PARTY INFORMATION


Name Marital Status

Last
First
Middle
Residence
Street

City
State
Zip
Mailing Address
Street

City
State
Zip
How long at this address Home Phone Work Phone
Previous Address
(if less than 3 years )
Street

City
State
Zip
Social Security # Birth date Relationship to Patient
E-mail address:

Employer Occupation Number Years Employed

Spouse's Name  Relationship to Patient

Last
First
Middle

Employer Occupation Number Years Employed
Social Security # Birth Date Work Phone

If parents are separated or divorced, who has financial responsibility?

INSURANCE INFORMATION


Do you have orthodontic insurance? Yes          No 

If yes, complete the following:

Insured's Name Social Security # Birthdate
Insured's Employer

Insurance Company Group Number Local Number

Insurance Company Address
Insurance Phone Number
Do you have dual coverage? Yes          No 
Insured's Name Social Security #Insured's Birthdate
Insured's Employer

Insurance Company Group Number Local Number
 

Insurance Company Address
Insurance Phone Number

To your knowledge, has the patient used any of their orthodontic benefits? Yes          No 

EMERGENCY INFORMATION


Name of nearest relative not living with you
Complete Address
Phone Number


MEDICAL HISTORY


YES NO     YES NO  
Is the patient in good health? Does the patient have any history of major illness?
Has the patient ever been under the care of a physician for illness?
If so, please list:
Have you ever had any of the following diseases or medical problems
YES NO     YES NO  
Abnormal Bleeding / Hemophilia Hepatitis / Liver Problems
Anemia Herpes
Arthritis High Blood Pressure
Asthma or Hayfever HIV + / AIDS
Bone Disorders Kidney Problems
Congenital Heart Defect Nervous Disorders
Diabetes Pneumonia
Dizziness Prolonged Bleeding
Epilepsy Radiation / Chemotherapy
Gastrointestinal Disorders Rheumatic Fever
Heart Problems Tuberculosis
Heart Murmur Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?

Does the patient have tendency to: Colds   
Sore Throat   
Ear Infections   
Have tonsils and adenoids been removed? What age?
List any drugs or medications now being taken. Give reasons:
List any allergies or drug sensitivity:
Has the patient reached puberty?
Girls - Has she started menstruation? Yes     No
Boys - Has his voice changed? Yes     No
Height:
Weight:

PATIENT DENTAL HISTORY


  YES NO
Has there been any injuries to the face, mouth, or teeth?
Has the patient ever sucked a thumb or fingers?
Does the patient have any speech problems?
Is the patient a mouthbreather while awake?
Is the patient a mouthbreather while asleep?
Has the patient been informed of any missing or extra permanent teeth?
Does the patient's teeth or jaws ever feel uncomfortable when they awake in the morning?
Is the pateint aware of their jaw clicking or popping?
Is the patient aware of clenching their teeth during the day?
Has the patient ever been told they grind their teeth?
Does the patient have "tension" headaches?
Has the patient ever experienced chronic ringing in their ears?
Has an orthodontist been consulted previously?
Has the patient ever experienced any unfavorable reaction to dentistry?
Are you aware some appointments will be during school/work hours?
What is the patient's attitude towards orthodontic treatment?
List any musical instruments played and hobbies:
Reasons for consultation: