Parent/Responisible Party - E-mail address:

Father Name: Address (if different): Street: City: State: ZIP: Mother Name: Address (if different): Street: City: State: ZIP:  Whom shall we contact if unable to reach mother or father? Name:      Relationship: Phone: Person responsible for account: Name:     Social Security # Relationship to patient:     Home phone: Work phone:     Employed by: Home address: Street:     City: State:     ZIP: Business address: Street:     City: State:     ZIP:

Employee/Subscriber Information (if you have orthodontic insurance)

Employee subscriber name:    SS# Employed by:    Subscriber date of birth: Subscriber's relationship to patient: Ortho insurance company name: Group #     Insurance company phone #

Dental History & Status

Have you ever had:   Yes  No     ●  Any injured or broken teeth?   |      ●  Any injuries to the head or face?   |      ●  Any problems with eating, chewing or swallowing?   |      ●  Any dental or facial pain?   |      ●  Any jaw joint noise or pain when opening, closing or chewing?   |      ●  Any unusual reaction to dental medications?   |      ●  A tooth clenching or grinding habit?   |      ●  Soreness in the muscles of the face?   |      ●  Difficulty breathing with your mouth closed?   |      ●  Swellings or growths in the mouth?   |      ●  Gums that bleed when brushing your teeth?   |      ●  A finger sucking habit?   |          If yes, is it still present?       ●  Previous orthodontic treatment or consultation?   |          When:     Whom:     ●  What do you think is your child's orthodontic problem?     ●  What does your child think about his/her teeth and the possibility of braces?             ●  Is there other information we should know?

Medical History

Yes  No     ●  Is your child presently in good health?   |          Date of last physical exam:     ●  Is your child being treated by a physician?   |          For what?     ●  Has your child been hospitalized or had a major illness in the last 5 years?   |          Please explain:     ●  Is your child taking any medications or drugs?   |          Please list:     ●  Is your child allergic to any drugs or medicines?   |          Please list:     ●  Are there any congenital problems?   |          Please list:     ●  Have tonsils/adenoids been removed?   |      ●  Females: Is there a current pregnancy?   |          If yes, give due date:     ●  Do sores occur in the mouth?   |      ●  Has a blood transfusion ever been given?   |      ●  Is antibiotic premedication needed before any dental appointments?   |      ●  Are there any learning disabilities or extra help needed for instructions?   |  Have the following ever been diagnosed or treated? Yes  No     ●  AIDS or HIV Positive?   |      ●  ADD (attention deficit disorder)   |      ●  Anemia   |      ●  Arthritis   |      ●  Bone disease   |      ●  Cancer or been treated for tumor   |      ●  Cerebral palsy   |      ●  Diabetes   |      ●  Dizziness/fainting spells   |      ●  Emotional or behavioral problems   |      ●  Epilepsy or neurologic problems   |      ●  Glaucoma   |      ●  Heart disorders   |      ●  Hepatitis or liver problems   |          If yes, hepatitis type:     ●  High or low blood pressure   |      ●  Hyperactivity   |      ●  Kidney problems   |      ●  Substance abuse problems   |      ●  Multiple sclerosis   |      ●  Immune system problems   |      ●  Prolonged bleeding   |      ●  Respiratory allergies   |      ●  Rheumatic fever   |      ●  Scarlet fever   |      ●  Shortness of breath   |      ●  Sickle cell anemia   |      ●  Sinus problems   |      ●  Stomach ulcers   |      ●  Thyroid or endocrine problem   |      ●  Tuberculosis   |      ●  Onset of puberty   |      ●  Other, please specify:     ●  Is there any other health information the doctors should be aware of?

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