Patient Name Preferred Name
Address City State Zip
Home Phone Birth Date Age Sex MaleFemale
Whom may we thank for referring you to our office?
Dentist Name Date of Last Visit
Is there anyone else in your family you would like us to see in the future?
Are there any other family members that already see us?
Chief Orthodontic Concern:
Primary Responsible Party Relationship to Patient
Home Phone Work Phone Cell Phone
Email Preferred Contact email home phone work phone cell phone text message
Social Security Number Birth Date
Employer Occupation # of Years Employed
Marital Status
Secondary Responsible Party Relationship to Patient
Insured's Name Birth Date SSN
Member/Subscriber # Phone
Insurance Company
Insurance Co Address City State Zip
Do you have dual coverage? noyes
2nd Insured's Name Birth Date SSN
Nearest relative not living with you Phone
Physician Date of Last Visit
Check the box if the patient has a history of the following:
Aids/HIV Cortisone Treatment Low Blood Pressure
Autoimmune Drug Allergies Nervous Disorder
Immune Problems Endocrine Problems Organ Transplant
Allergies Seasonal Allergies Emotional Disorders
Painful Chewing Epilepsy Periodontal Problems
Anemia Fainting, Dizziness Liver Problems
Arthritis Headaches Diabetes
Asthma Heart Condition Prolonged Bleeding
Bone Disorders Congenital Heart Condition Radiation Treatment
Cancer Chest Pains Rheumatic Fever
Cerebral Palsy Artificial Heart Valves Seizures
Muscular Disorders High Blood Pressure Thyroid
Jaw Clicking Tooth Grinding Cold Sores
Chronic Neck Pain Hepatitis TMJ Problems
Kidney Problems Tuberculosis Latex Sensitivity
Have tonsils and adenoids been removed? yesno What age?
Currently pregnant? select one yes no possibly
List any drugs or medications now being taken, give reason
A checked box indicates a "yes" to the question, a unchecked box will indicate a "no" to the question.
Have there been injuries to the face, mouth, or teeth?
Does the patient suck their thumb or finger? does notcurrently doeshas in the past
Does the patient have jaw pain or tiredness?
Does the patient have pain around ear?
Does the patient suffer from dry mouth?
Does the patient grind their teeth?
Have you been informed of any missing or extra permanent teeth?
Has an orthodontist been consulted previously?
Has the patient had previous orthodontic treatment?
or