Welcome to Our Office! Please Assist Us by Completing the Following Information

Welcome to our office! Please assist us by completing the following information.

Name______Nickname______Date______

Address______City______State_____Zip______

Home Phone ______Birthdate______Age______Sex______

E-mail______Cell number______

School______Grade______

Father’s Name______

Employer______Work Phone______

Mother’s Name______

Employer______Work Phone______

Patient lives with: both parents mother father other______

Person responsible for account ______So.Sec. #______

I, ______( responsible party) understand that credit bureau reports may be obtained before the start of orthodontic treatment.

X______(Signature of responsible party)

Brothers Sisters

______Age______Age_____

______Age______Age_____

______Age______Age_____

In case of emergency please contact:______Phone______

Dental Insurance

Policy Holder Name______Insurance Company______ID# ______

Relationship to patient ______Birthdate ______Employer ______

Dental History

Dentist______Date of last visit______were x-rays taken?______

Reason for seeking orthodontic treatment______

When did you 1st become aware of the problem?______

Whom can we thank for referring you to our office?______

Yes No

Have you seen an orthodontist concerning this problem?__ __

Has anyone in your family had orthodontic treatment?__ __

Does anyone in your family have a similar dental problem?__ __

Does the patient have any of the following:

Yes No Yes No

speech problems or therapy__ __jaw pain or clicking__ __

tongue thrust __ __clenching or grinding teeth __ __

difficulty chewing or swallowing food__ __teeth or gum sensitivity __ __

frequent headaches__ __bleeding gums__ __

teeth removed by a dentist__ __

Have there been any injuries to the face, mouth, or teeth? If so please explain.______

Has the patient had any of the following habits: Thumb/finger sucking, lip biting, or fingernail biting, if so until what age?______

Does the patient play a musical instrument?______Kind______

Any special interests (sports, hobbies, etc.)______

Medical History

Date of last physical examination______Current Height______Weight______

Is the patient currently under the care of a physician? ______If so, why?______

Is the patient taking any medication now?______If so, for what?______

Has the patient ever been treated for any of the following?

Yes NoYes No Yes No

Diabetes__ __Tuberculosis __ __Endocrine Problems __ __

Pneumonia__ __ Anemia __ __Prolonged Bleeding __ __

Heart Problems__ __Epileps __ __Liver Problems __ __

Rheumatic Fever__ __Asthma __ __Fainting or Dizziness __ __

Bone Disorders __ __Kidney Problems __ __Nervous Disorder __ __

Hepatitis__ __Thyroid Problems __ __

Does the patient often have colds, sore throats, or ear infections?______

Does the patient have difficulty in breathing through his/her nose? ______

Have the tonsils and adenoids been removed? At what age?______

Please list any allergies or drug sensitivities.______

Please describe any present or past medical problems, hospitalizations ,operations or special problems not mentioned above.

______