Step 1 of 5 - Patient Information 20% Today’s date Patient's name* First Last Nickname Birthdate* MM slash DD slash YYYY Age*Sex Male Female Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneIf patient is a minor, give parent's/guardian's name Hobbies/interests School/Occupation Grade Sisters/Brothers or Daughters/Sons (names/ages)*Close friend or relative who is a patient here Has the patient had a previous orthodontic consultation?* Yes No Previous orthodontic treatment?* Yes No If so, when/where? Dr.'s name What is it about your teeth/bite and/or appearance that has brought you to see us?*Who may we thank for referring you to our office?* Name* Relationship to the patient* Marital Status Single Married Widow Divorced Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneMobile*Employer Occupation No. yrs. emp’d. Social Security No./ Subscriber ID Drivers License Birthdate MM slash DD slash YYYY Email address Spouse’s name Relat. to patient Employer Occupation No. yrs.emp’d. Note:-If no insurance, please skip to step 4.Name of Insured Relat. to Pt Insurance Company Name TelephoneEmployer Occupation No. yrs.emp’d.Social Security No./ Subscriber ID Drivers License Birthdate MM slash DD slash YYYY How does the patient feel about wearing "braces"? Does anyone else in the family have a similar orthodontic problem? Yes No Who? Patient's dentist* Does the patient receive regular dental checkups?* Yes No Last dental exam* Last dental X-rays* Other dental specialistsIs patient satisfied with past dentistry?* Yes No Any unfavorable dental experiences?Does the patient currently have, or has the patient ever had any of the following? Thumb/finger habit Nail biting Periodontal disease Gum surgery/food traps Head/neck injury Jaw/joint pain/head/neck pain Cold sores/clenching/grinding Adult/baby/wisdom tooth extractions Is there any other dental information we should know about? Patient's Physician Patient's overall health status?* Excellent Good Poor Is the patient allergic to anything (drugs, food, pollen)?* Is the patient presently under medical care?* Yes No For what/where? Is the patient currently taking any medications?* Has the patient ever been hospitalized? Yes No When/ Where? Does the patient currently have, or has the patient ever had any of the following? Adenoids removed AIDS (HIV) Arthritis Auto accident Bleeding disorders Cancer Cosmetic surgery Diabetes Drug addiction Epilepsy/seizures Heart problems Hepatitis High blood pressure Immune disorders Kidney problems Liver problems Lung problems Major surgery Nasal/airway problems Sinus problems Speech problems Tobacco usage Tonsils removed Tuberculosis Tubes in ears Venereal disease Is there any other medical information that we should know about?Signature*Patient's/Parent's signature to verify above information
