First Name:*
Last Name:*
Gender:*
MaleFemale
Date of Birth:*
Address:*
City:*
Postal code:*
Home Phone:*
Cell Phone:*
Email:*
Best Time To Call:
School:
Family Dentist:
How did you hear about our office?
DentistNewspaperInternetFriendsOther
Dentist/Other:
Responsible Party I
Name:
Occupation:
Contact #:
Relationship with patient:
Email:
Do you have DENTAL INSURANCE that covers orthodontic treatment?
yesno
Insurance company:
Subscriber's name:
Subscriber/ Policy number:
Group ID number:
When was your last visit to a family doctor?
How long ago was your last visit to a dentist?
Last radiographs taken (Panoramic X-ray):
Are you in good general health? YesNo
Have you had any serious chronic illnesses or operations? YesNo
Do you require pre-medication before dental work? YesNo
If yes, what condition is this for?
Do you have a history of any of the following:Heart problemsHepatitisRheumatic feverAllergiesDiabetesAsthmaFaintingSeizuresArthritis
if checked, please explain
Do you have any of the following habits? snoring and/or mouth breathing YesNoBoth
Do you have any difficulty opening the mouth? YesNo
Do you hear ‘popping’ or ‘clicking’ noises from the jaw joints? YesNo
Do you have pain around the ears or cheek? pain on opening wide, chewing or yawning? YesNo
Have your jaw ever been locked or dislocated? YesNo
Have you ever had injury to the following
JawTeethMouthHeadNeck
Does your bite feel uncomfortable or unusual? YesNo
Have you been treated for TMJ (Temporomandibular disorder)? YesNo
Are you under any stress? YesNo
Is there any other health information that we should know about?
Are you taking any medications?
Have you had any previous orthodontic treatment? YesNo
If yes, please explain:
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