Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:
Nickname:
Gender:
Address:
City:
State:
Zip:
Phone:

Activities:
Whom may we thank for referring you to our practice?
Who is with the Child Today?

Responsible Party Information

First Name:
Middle Initial:
Last Name:
Cell Phone:
Employer:
Work Phone:
Email Address:

If different from patient information, please complete

Address:
City:
State:
Zip:

Responsible Party Information 2

First Name:
Middle Initial:
Last Name:
Cell Phone:
Employer:
Work Phone:
Email Address:

If different from previous information, please complete

Address:
City:
State:
Zip:

Medical and Dental History

Dentist:
Date of Last Visit:
Is your dentist recommending any dental work at this time?
Physician:
Date of Last Visit:

Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness or operations?
Have you ever been involved in a serious accident?
Please select 'Yes' for any of the medical conditions below that you have had or currently have.
Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma or Hay fever
Bone Disorders
Congenital Heart Defect
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur?
Hepatitis/Liver problems
Herpes
High Blood Pressure
HIV / AIDS
Kidney problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer
If any of the above questions were answered 'Yes', please explain:
Do you or have you ever had TB?
Do you have a chronic cough?
Do you ever cough up blood?
Do you have night sweats?
Are there any other medical conditions you feel we should be aware of?
What concerns you most about your teeth?
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have there been any injuries to face, mouth or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist? If yes, who and when?
Has anyone in your family received orthodontic treatment?
How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have 'tension' headaches?
Female patients only: Are you pregnant?
If any of the above questions were answered 'Yes', please explain:

I consent to the taking of photographs and X-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I understand taht the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my medical status. I authorize the Orthodontist to share this patient's treatment information with collaborating dentist and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the insurance company for billing purposes only.

Signature of self, parent or guardian:
Date: