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: