PATIENT INFORMATION

• Sex MaleFemale
• HomeCell
• OK to leave message? YesNo
• HomeCellOther
• OK to leave message? YesNo

SPOUSE/EMERGENCY CONTACT INFORMAITON

• Marital Status*SingleMarriedDivorcedWidowedSignificant Other

DENTAL INSURANCE INFORMATION

DENTAL HISTORY

• How did you hear about our practice? AdInternetFamily or FriendPhysicianOther
• What are the main concerns you would like orthodontics to accomplish?
• Have you visited an orthodontist before? YesNo
• Have your tonsils or adenoids been removed?YesNo
• Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNo
• Do you have any missing or extra permanent teeth?YesNo
• Have you ever had an injury to (select all that apply)?TeethMouthChinSelect All That Apply
• Do you have speech problems?YesNo
• Do your gums bleed? YesNo
• Do you smoke? YesNo
• Do you like your smile?YesNo
• Do you currently or have you ever had any of the following habits (select all that apply)?
  Clenching/Grinding TeethMouth BreathingThumb/Finger SuckingLip Sucking/BitingNail BitingChewing/Eating Problem

MEDICAL HISTORY

• Are you currently being treated by a physician?YesNo
• Do you have any allergies/sensitivities to medications or latex?YesNo
• Are you currently taking any prescription over-the-counter medications?YesNo
• Have you had any serious illnesses or operations?YesNo
• Have you ever had a blood transfusion?YesNo
• Are you pregnant?YesNo
• Nursing?YesNo
• Are You Taking Medications For Osteoporosis?YesNo
• If Yes Name Of Medication
• Check if you have ever had any of the following?
  AnemiaArthritis RheumatismArtificial Heat ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

AUTHORIZATION

• I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.
• I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.
• I understand that where appropriate, credit bureau reports may be obtained.