Orthodontic Patient Information
Welcome to our Office!
Name:
Sex:
Date of Birth:
Age:
Address:
Home Phone:
City:
State:
Zip:
Work Phone:
Employer/School:
Person(s) financially responsible
Name:
Relation to patient:
Address:
Home Phone:
City:
State:
Zip:
Work Phone:
Place of Employment:
Mobile Phone:
SSN:
Date of Birth:
Email:
Name:
Relation to patient:
Address:
Home Phone:
City:
State:
Zip:
Work Phone:
Place of Employmen:
Mobile Phone:
SSN:
Date of Birth:
Email:
Is the patient covered by insurance for orthodontic treatment?
No
Yes
DENTIST
Name:
Address:
City:
State:
Zip:
Phone:
PHYSICIAN
Name:
Address:
City:
State:
Zip:
Phone:
REFFERED BY
Name:
Address:
City:
State:
Zip:
Phone:
Is the patient married
No
Yes
Spouse:
Medical History
Has the patient ever had: (circle all that apply)
Allergies
Anemia
Arthritis
Asthma
Bleeding
Cold Sores
Diabetes
Endocrine Problems
Emotional Problems
Epilepsy/Seizures
Heart Condition
Head/Face Injury
Hepatitis
HIV +
Kidney Disease
Lung Disease
Oral Ulcer
Previous Surgery
Rheumatic Fever
Thyroid Problems
Other
Has the patient been under the care of a physician during the past two years, other than for routine?
No
Yes
condition:
Birth Defects:
Respiratory History
Does the patient:
Have allergies to:
Latex
Seasonal Grasses
Any Metal
Drugs
Food
Other
2. Breathe through mouth?
No
Sometimes
Usually
3. Snore when sleeping?
No
Sometimes
Usually
4. Have frequent colds?
No
Yes
5. Have frequent “stuffy nose?”
No
Yes
6. Have frequent sore throat or tonsillitis?
No
Yes
7. Have chewing or swallowing difficulty?
No
Yes
Has the patient received medical treatment from allergist or ear, nose and throat specialist?
No
Yes
When
By Whom
Nasal Surgery
Tonsils removed
Adenoids removed
Dental and Temporomandibular Joint History
Has the patient had any unusual dental experiences?
Date of last dental checkup
Were the patient′s teeth cleaned?
Has the patient ever been treated for T.M.J. (“Jaw Joint”) problem?
Does the patient have:
1. Difficulty in mouth opening?
No
Yes
2. Pain or clicking in jaw joint?
No
Yes
3. Pain in chewing, yawning or wide opening?
No
Yes
4. Pain in or about the ears or cheeks?
No
Yes
5. A bite that feels uncomfortable or unusual?
No
Yes
6. A jaw that locks, gets stuck or goes out?
No
Yes
7. Noises in or from the jaw joints?
No
Yes
The following habits are of interest. List information as it pertains to this patient:
1. Thumb/Finger/Lip sucking
No
Yes
until (age)
2. Grinding or Clenching of teeth
No
Yes
3. Tongue thrusting or other functional problems
No
Yes
Has the patient had previous orthodontic consultation?
No
Yes
Treatment?
No
Yes
Date
Dr.:
Why did patient seek this consultation/what is the primary problem?
What is expected from orthodontic treatment?
Signature of individual completing this form:
Relationship of patient:
Today′s Date:
Doctor reviewed medical history:
Date updated medical history:
Date updated medical history: