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Patient Last Name:	Patient First Name:	Patient Middle Name:	Patient Preferred Name:
Patient Birthday:	Patient Age: Patient Status: SingleMarriedWidowedSeperatedDivorced	Patient Gender: MaleFemale	Patient SSN/SIN:
Patient Email:	Patient Home Phone:	Patient Cell Phone:	Patient Pager:
Patient Address:	Patient City:	Patient State:	Patient Zip:
Patient Job Title:	Patient Employer:	Years With Employer:	Employer Phone:
Spouse Name:		Spouse Phone:	Spouse Relationship:
Spouse Address:	Spouse City:	Spouse State:	Spouse Zip:
Dentist:	Dentist Phone:	Last Visit:
Dentist Address:	Dentist City:	Dentist State:	Dentist Zip:
Physician:	Physician Phone:	Last Visit:
Physician Address:	Physician City:	Physician State:	Physician Zip:
Who is financially responsible
Last Name:	First Name:	Middle Name:	Preferred Name:
Address:	City:	State:	Zip:
Who suggested that you might need treatment?		Why did you select our office?
Ins. Coverage For Dental YesNo		Ins. Coverage For Orthodontic YesNo
Primary Policy Holder:	SSN/SIN:	Birthday:	Employer:
Insurance Company		Group Number
Secondary Policy Holder:	SSN/SIN:	Birthday:	Employer:
Insurance Company		Group Number

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For the following questions, mark Y (Yes), N (No) or U (Unknown). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.
Medical History
Birth defects or hereditary problems? Y N U	Rheumatoid or arthritic conditions? Y N U	Bone fractures, any minor accidents? Y N U	Cancer, tumor, radiation treatment or chemotherapy? Y N U
Polio, mononucleosis, tuberculosis, pneumonia? Y N U	Problems of the immune system? Y N U	Does patient wear an artificial prothesis? Y N U	Eye, ear, nose or throat condition? Y N U
Hayfever, asthma, sinus trouble or hives? Y N U	Loss of weight recently, poor appetite? Y N U	Vision, hearing, tasting or speech difficulties? Y N U	Fainting spells, seizures, epilepsy or neurological problem? Y N U
Chest pain, shortness of breath or swelling ankles? Y N U	Kidney Problems? Y N U	Endocrine or thyroid problems? Y N U	Diabetes? Y N U
Stomach ulcer or hyperacidity? Y N U	Tonsil or adenoid conditions? Y N U	AIDS or HIV positive? Y N U	High or low blood pressure? Y N U
Tired easily? Y N U	Skin disorder? Y N U	Osteoporosis? Y N U	History of eating disorder? Y N U
Hepatitis, jaundice or liver problem? Y N U	Mental health disturbance or depression? Y N U	Frequent headaches, colds or sore throats? Y N U	Does patient have a well-balanced diet? Y N U
Excessive bleeding or bruising tendency, anemia or bleeding disorder? Y N U Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, asteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)? Y N U
Allergy History
Local anesthetics (Novocaine etc.) Y N U	Aspirin Y N U	Ibuprofen (Mortin, Advil) Y N U	Penicillin or antibiotics Y N U
Sulfa drugs Y N U	Codeine or narcotics? Y N U	Metals (jewelry, buttons) Y N U	Latex (gloves, balloons) Y N U
Vinyl Y N U	Acrylic Y N U	Animals Y N U	Tobacco user? Y N U
Foods Y N U		Other substances Y N U
Specify		Specify
Is patient taking medication, nutrient supplements, herbal medications or non prescription medicine? Please name them. Y N U		Medicine Taken For	Medicine Taken For
Operations Y N U     Describe: Hospitalized Y N U     For: Physical problems Y N U     For:
Substance abuse problem Y N U     Describe: Treated by health care professional Y N U     For: Other medical conditions Y N U     List:

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Dental History
Permanent or "extra" teeth removed? Y N U	Extra or congenitally missing teeth? Y N U	Chipped or otherwise injured teeth? Y N U	Teeth sensitive to hot or cold; throb or ache? Y N U
Jaw fractures, cysts or mouth infections? Y N U	"Dead teeth" or root canals treated? Y N U	Bleeding gums, bad taste in mouth odor? Y N U	Food impaction between teeth? Y N U
"Gum boils", frequent canker sores or cold sores? Y N U	Thumb, finger, or sucking habit? Y N U	Abnormal swallowing habit? Y N U	History of speech problems? Y N U
Tooth grinding or jaw clenching? Y N U	Breathing habit, snoring or difficulty breathing? Y N U	Clicking or locking jaw, ringing in the ears? Y N U	Difficulty in chewing or opening jaw? Y N U
Pain or sore in the muscles of the face? Y N U	Treated for TMD or TMJ? Y N U	Aware of loose, broken or missing restorations? Y N U	Any teeth irritating cheek, lip, tongue? Y N U
Concern about spaced, crooked or protruding teeth? Y N U	Concern about over or under developed jaw? Y N U	Relatives with similar tooth/jaw problems? Y N U	Any wisdom tooth problems? Y N U
Had periodontal (gum) treatment? Y N U	Had trouble with previous dental treatments? Y N U	Ever had prior orthodontic treatment? Y N U	Objection to wearing braces if they are needed? Y N U
Under another dentist's care? Y N U Specialist: Other:
Family Medical History
Bleeding disorders? Y N U     Info:	Diabetes Y N U     Info:	Arthritis Y N U     Info:	Severe Allergies Y N U     Info:
Unusual Dental Problems Y N U     Info:	Jaw Size Imbalance Y N U     Info:	Other family medical conditions that we should know about? Y N U     Info:
Women Only
Are you pregnant? Y N U	Are you anticipating becoming pregnant? Y N U

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The following questions are specifically for minors, if you are not filling this out for someone under 18 years of age, you do not have to complete this page.
Child Information
Childs School:	Childs Grade:	Musical Instruments:	Sports/Hobbies:
Child Profile
Follow Directions Well? Y N U	Brushes Teeth Regularly? Y N U	Need Help With Instructions? Y N U	Self-Conscious About Teeth? Y N U
Girls Only
Started Monthly Period? Y N U	If So, About When:	Is Pregnant? Y N U
Siblings
Name: Age:	Name: Age:	Name: Age:	Name: Age:

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