Form

Patient's First Name

M.I.

Patient's Last Name

Age

Patient's Date Of Birth

Address

City

Zip Code

Best # to Call

Preferred Email Address

Father's Information

First Name

M.I.

Last Name

Date Of Birth

SSN (for accounting purposes only)

Address

City

Zip Code

Phone

Employed By

Occupation

Position

Office Address

Work Phone #

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Please upload a picture of your dental insurance card here.

Insurance card front

Upload or drag files here

Insurance card back

Upload or drag files here

Mother's Information

First Name

M.I.

Last Name

Date Of Birth

SSN (for accounting purposes only)

Address

City

Zip Code

Phone

Employed By

Occupation

Position

Office Address

Work Phone #

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Responsible Party (if other than the patient's parents):

Is the responsible party authorized to sign consent on behalf of patient?

Name

SSN

Date Of Birth

Relationship to patient

Address

City

Zip Code

Phone

Orthodontic Insurance?

Name of Insurance CO

ID#

Group #

Medical Insurance?

Name of Insurance CO

ID#

Group #

Please upload pictures of your dental insurance card if applicable:

Back of Card

Upload or drag files here

Front of Card

Upload or drag files here

Patient's Family Dentist

Patient's Family Physician

Whom may we thank for referring you to our office?

MEDICAL HISTORY:

Has the patient had or does the patient have any of the following?

Rheumatic Fever

Heart Murmur

High Blood Pressure

Heart Attack/Stroke

Blood Vessel Disease

Blood Disorder

AIDS/HIV Infection

Hepatitis

Diabetes

Ulcers

Herpes (Any type)

Psoriasis

Cancer

Persistent Headaches

Neck Pains

Nerve or Brain Disease

Migraine

Epilepsy

Mental Health Problems

Bone Disorders

Arthritis (Any type)

Artificial Joints

Sleep Apnea

Ear Disorder

Sinus Infection

Swollen Glands

Allergies

Please list any other significant information about the patient's medical history:

Is the patient under a physician's care at present?

If yes, reason

Is the patient presently, or have you ever been, under the care of a psychiatrist or psychologist?

If yes, reason

Is the patient currently taking any medication?

If yes, describe

Is the patient allergic to any medications? (e,g: aspirin, penicillin, etc.)

If yes, describe

Has the patient ever had any general anesthesia?

When?

Do any of the patient's teeth hurt?

If yes,

Has the patient had any wisdom teeth removed?

How many?

Has the patient ever had treatment for a periodontal disease (gum disease)?

If yes, describe

Has the patient ever had any previous orthodontic treatment (braces)?

If yes, when

If yes, doctor's name and address:

Have there been any injuries to the patient’s mouth or teeth?

If yes, describe

Has the patient ever had any injury in the head and neck area?

If yes, describe

Has the patient ever fallen and bumped his/her chin, or received a blow to the jaws?

If yes, describe

Has the patient ever had any surgery in the head and neck area?

If yes, describe

Does the patient clench or grind his/her teeth?

If yes,

Other

Do the patient’s jaw muscles ever feel tired?

If yes, when

Does the patient ever notice soreness, tightness or pain in the muscles around the jaws and face?

If yes, describe

Does it hurt to chew?

If yes, where does it hurt?

Does the patient hear clicking (popping) or grating sounds in his/her jaw joints?

Check all that apply

Did these sounds begin gradually or suddenly?

When did it start and during what activity?

Please describe the specific event that started the joint sounds, if applicable.

Has the patient ever experienced difficulty in opening or closing his/her jaws?

If yes, describe

Have the patient’s jaws ever “locked” closed or wide open?

If yes, describe

Does the patient have pain in his/her jaw joints?

If yes, which side of the mouth? Since when?

Did your pain start gradually or suddenly?

During what activity?

Describe nature of pain

What increases/decreases the pain?

Does the patient have any of the following habits?

Finger/Thumb Sucking

Lip Biting

Nail Biting

Gum Chewing

Ice Chewing

Has the patient reached adolescent growth?

Girls -Has monthly cycle started yet?

If so, when

Boys - Has voice changed yet?

If so, when

Is the patient adopted?

Does the patient know?

Are there any learning disabilities?

If yes, explain

Please describe why you sought this consultation

Has the patient ever been treated for this problem before?

If yes, please describe the diagnosis and treatment:

Have any other members of the family had orthodontic treatment?

Have any other members of the family been patients in this office?

Names?

Are there other children in the family?

Names and ages

Any information you can give us concerning your child will be appreciated. The more we know about each patient, the better we can manage the orthodontic treatment, both at home and in the office. Also, please include special interests and hobbies:

I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.