Has the patient been examined by an orthodontist before?
GUARDIAN #1 / INSURANCE INFORMATION
Guardian's First Name
Guardian's Last Name
Guardian's Address
City
State
Zip
Guardian's Phone
Guardian's Email
Employer
Date of birth
Social Security Number
ORTHODONTIC INSURANCE (IF APPLICABLE):
Company Name
Phone
Subscriber/Member ID
SLEEP / AIRWAY ISSUES
Does the patient tend to be a mouthbreather?
Does the patient snore at night?
Does the patient seem rested in the morning?
Is the patient often sleepy during the day?
Has the patient seen an Ear, Nose & Throat Specialist?
Is the patient using a sleep apnea device?
Please check if the patient has a history of the following medical conditions:
Acid Reflux
ADHD/ADD
AIDS/HIV
Anemia
Arthritis
Asthma
Autism
Bone Disorders
Cancer
Cerebral Palsy
Chest Pain
Chronic Neck Pain
Clicking of Jaw
Cold Sores/Herpes
Diabetes
Down Syndrome
Endocrine Problems
Emotional Disorders
Epilepsy
Headaches
Heart Condition
Hepatitis
Ear Pain
Immune Problems
Kidney Problems
Low Blood Pressure
Muscular Disorders
Nervous Disorders
Organ Transplant
Osteoporosis
Painful Chewing
Periodontal Problems
Prolonged Bleeding
Rheumatic Fever
Scoliosis
Seizures
Sinus Problems
TMJ Problems
Tuberculosis
Please check if the patient has a history of the following medical conditions:
Do your gums bleed when you brush?
Is the patient seeing any other dental specialists?
Any dental restorations needing to be completed?
Have there ever been any injuries to the face, mouth or chin?
Have you ever lost or chipped any teeth?
Do you have any pain or soreness around your face, neck or back?
Is any part of your mouth sensitive to temperature or pressure?
Is the patient currently pregnant?
Have adenoids been removed?
Have tonsils been removed?
Currently taking any medications?
Are antibiotics necessary prior to treatment?
Allergies?
Any diseases or problems not mentioned above?
Please check if the patient has, or ever had, any of the following habits?
Cheek, tongue or lip biting
Clenching Teeth
Fingernail Biting
Grinding Teeth
Tongue Sucking
Thumb Sucking
Tongue Thrusting
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status. I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
Typed Name/Signature
Relationship to Patient
Date
If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:
By submitting this form you agree to the above mentioned consent statement
