Patient Name
Address
Town
Zip Code
Gender
MaleFemale
Home Phone
Business Phone
Cell Phone
Email Address
Who Referred You?
Birth Date
Birthplace
Marital Status
MarriedSingleDivorcedSeparatedWidowed
Dentist's Name
Date Of Last Checkup
Physician's Name
Date Of Last Checkup
Your Occupation
Your Social Security
Spouse's Name
Spouse's Occupation
Spouse's Employer Name & Address
Spouse's Date Of Birth
Spouse's Social Security
Spouse's Phone
Are Any Family Members Currently In Treatment?
YesNo
If So, Why?
Currently Wearing Braces?
YesNo
Currently Wearing Retainers?
YesNo
Has An Appliance?
YesNo
Invisalign?
YesNo
Waiting To Begin Treatment?
YesNo
1. What Are The Main Concerns That You Would Like Orthodontics To Accomplish?
2. Are You In Good Health?
YesNo
3. Do You Have Regular Medical Examinations?
YesNo
4. Have You Ever Had Any Of The Following? (Please Check)
Allergies To Any Drugs?
5. Do you require pre-medication for any condition, If so, What?
6. Is there anything else we should know about your general health? Such as allergies to medications, food, Latex, etc
7. Have you ever had any injuries to the face, mouth, teeth, or chin? If yes, please explain
8. Are you a mouth-breather? If yes, please explain
9. Is there a hereditary background that might contribute to your dental problem
YesNo
10. Have you ever had any pain / tenderness in their jaw joint (TMJ)?
YesNo
11. Other Remarks
13. Do you have Insurance?
14. Name Of Insurance Company?
By entering your initials, you are providing your signature electronically.