PATIENT INFORMATION


Child's Name Last
First
Middle

Address
Street

City
State
Zip

Phone Birth date

Age

 S.S.N. E-mail address

School Grade

Siblings / Children     (Names and ages 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

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

INSURANCE INFORMATION


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

Insurance Company Group Number Local Number
 

Insurance Company Address
Insurance Phone Number

DENTAL and MEDICAL HISTORY

Dentist First Last
Last Visit: 3 months / 6 months / 12 months
Who may we thank for referring you?
If your dentist referred you, were you given a choice of orthodontist? Yes No
Do you have friend/family with braces? Yes No
What is the patient's chief concern?
Is there anything that you would change about your smile (or your child's smile)?

  YES NO
Has the patient had orthodontic treatment in the past?
Orthodontist: City: State: Tx:    
Have parents had orthodontic treatment?
Have siblings had orthodontic treatment?
Have you already consulted with another orthodontist?
Has patient ever had dental trauma? (broken, chipped, knocked out)
Has patient ever had extractions?
If yes, which teeth?    
Has patient been treated for periodontal problems?
Has patient had any dental/TMD surgeries?

Have you or your child 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?

Allergies:
YES NO    
Allergies to medication ? Which ones?
Allergies to latex ?  
Allergies to sulfur drugs?  
Allergies to nickel? Other allergies ?
 
Medications:
Is the patient currently under medication? Yes   No
List Medications:
Do you take Bisphosphonates such as Fosamax, Zometa, Didronel, Aredia, Actonel or Boniva? Yes   No
 
Premedication:
Does the patient premedicate for dental visits due to a heart murmur or heart problem? Yes    No
If yes, which antibiotic have you been prescribed?

If the Patient is a Child:
YES NO    
Speech therapy? If yes, what age?
Sucking habits ? If yes, what age did they stop?
Has the patient reached puberty? If yes, what age?
Does patient play a musical instrument that fits between the teeth?