Today's Date: August 28, 2008

1.  About You:
E-mail Address:
Name:
Title: Mr. Mrs. Ms. Dr.
I prefer to be called:
Gender: Male Female
Birthdate:  Age:  SS#:
Home Address:

Single Married Divorced
Widowed Separated
Home #:  Pager/Other #:
Work #:   Ext:
DL #:
Employer:
Employer's Address:
How long there?
Occupation:
Where & when are the best times to reach you?
Who may we thank for referring you?
Other family members seen by us:
General dentist:
Last visit date:

2.  Spouse Information:
His/Her name:
Employer:
Work #:  Ext:  SS#:  
Birthdate:

Person Responsible for Account:
Name:
Work #:  Ext:  Home #:
Billing Address:
Relation:  
SS#:
Employer:  
DL#:

In the event of an emergency, is there someone who lives near you that we should contact?
Name:
Relation:
Work #:  
Home #:

3.  Orthodontic Insurance:
Primary Orthodontic Coverage? Yes No
Dental Coverage: Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy#):
Insured’s Name:
Relation:
Insured’s Birthdate: SS#:
Insured’s Employer:
Secondary Orthodontic Coverage: Yes No
Dental Coverage: Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy#):
Insured’s Name:
Relation:
Insured’s Birthdate: SS#:
Insured’s Employer:

4.  Medical History:
Do you have a personal physician? Yes No
Physician's Name:
Phone #:
Date of last visit:
Your current physical health is:
Good Fair Poor
Are you currently under the care of a physician?
Yes No
If yes, please explain:

Are you taking any prescription/over-the-counter drugs?
Yes No
Please list each one:

For Women:
Are you taking birth control pills? Yes No
Are you pregnant? Yes No
If yes, Week #:
Are you nursing? Yes No

Medical History, Cont'd:

Have you ever had any of the following diseases or medical problems?
Y N   Abnormal Bleeding
Y N   Anemia
Y N   Artificial Bones/Joints/Valves
Y N   Asthma/Arthritis
Y N   Blood Transfusion
Y N   Cancer/Chemotherapy
Y N   Congenital Heart Defect
Y N   Diabetes
Y N   Difficulty Breathing
Y N   Drug/Alcohol Abuse
Y N   Emphysema
Y N   Epilepsy/Seizures/Fainting
Y N   Fever Blisters/Herpes
Y N   Glaucoma
Y N   Heart Attack/Stroke
Y N   Heart Murmur
Y N   Heart Surgery/Pacemaker
Y N   Hemophilia
Y N   Hepatitis
Y N   High/Low Blood Pressure
Y N   HIV+/AIDS
Y N   Hospitalized for any reason
Y N   Kidney Problems
Y N   Mitral Valve Prolapse
Y N   Psychiatric Problems
Y N   Radiation Treatment
Y N   Rheumatic/Scarlet Fever
Y N   Severe/Frequent Headaches
Y N   Shingles
Y N   Sickle Cell Disease/Traits
Y N   Sinus Problems
Y N   Tuberculosis (TB)
Y N   Ulcers/Colitis
Y N   Veneral Disease

Medical History, Cont'd:

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?
Y N   Aspirin
Y N   Any Metals/Plastics
Y N   Codeine
Y N   Dental Anesthetics
Y N   Erythromycin
Y N   Latex
Y N   Penicillin
Y N   Tetracycline
Y N   Other

Please list any other drugs/materials that you are allergic to:

5.  Dental History:
What are the main concerns that you would like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic treatment?
Yes No
Have you ever had a serious/difficult problem associated with any previous dental work?
Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMDJ)?
Yes No
Your current dental health is:
Good Fair Poor
Do you like your smile?
Yes No
Gums ever bleed?
Yes No
Have you ever had an injury to your:
Mouth Teeth Chin
Do you have any speech problems?

Do you generally breathe through your mouth?
Yes No
If yes: While awake? While asleep?

Do you have any missing or extra permanent teeth?
Yes No
Have you ever taken Phen-Fen? Also known as Redux or Pondimin)
Yes No
If yes, when?