Patient’s Information:

First Name:*

Last Name:*

Gender:*
MaleFemale

Date of Birth:*

Address:*

City:*

Postal code:*

Home Phone:*

Cell Phone:*

Email:*

Best Time To Call:

School:

Family Dentist:

How did you hear about our office?
DentistNewspaperInternetFriendsOther

Dentist/Other:

Responsible Party

Responsible Party I

Name:

Occupation:

Contact #:

Relationship with patient:

Email:

Insurance Info

Do you have DENTAL INSURANCE that covers orthodontic treatment?
yesno

Insurance company:

Subscriber's name:

Subscriber/ Policy number:

Group ID number:

Dental / Medical History

When was your last visit to a family doctor?

How long ago was your last visit to a dentist?

Last radiographs taken (Panoramic X-ray):

Are you in good general health? YesNo

Have you had any serious chronic illnesses or operations? YesNo

Do you require pre-medication before dental work? YesNo

If yes, what condition is this for?

Do you have a history of any of the following:Heart problemsHepatitisRheumatic feverAllergiesDiabetesAsthmaFaintingSeizuresArthritis

if checked, please explain

Do you have any of the following habits? snoring and/or mouth breathing YesNoBoth

Do you have any difficulty opening the mouth? YesNo

Do you hear ‘popping’ or ‘clicking’ noises from the jaw joints? YesNo

Do you have pain around the ears or cheek? pain on opening wide, chewing or yawning? YesNo

Have your jaw ever been locked or dislocated? YesNo

Have you ever had injury to the following

JawTeethMouthHeadNeck

Does your bite feel uncomfortable or unusual? YesNo

Have you been treated for TMJ (Temporomandibular disorder)? YesNo

Are you under any stress? YesNo

Is there any other health information that we should know about?

Are you taking any medications?

Have you had any previous orthodontic treatment? YesNo

If yes, please explain: