ABOUT YOU Today's Date: Name: Last Name First Name Title I prefer to be called: MALE    FEMALE Birthdate: Age:   SS#: Home Address: Street City State ZIP Marital Status: Single  Married  Divorced  Widowed  Separated Home Phone: Work Phone: Employer: Employer's Address: Street City State ZIP Occupation: Where and when are the best times to reach you?: Whom may we thank for referring you?: Other family members seen by us: General Dentist: Last Visit Date:

SPOUSE INFORMATION Name: Last Name First Name Title Employer: Work Phone: Birthdate: SS#: Person Responsible for Account: Work Phone: Home Phone: Billing Address: Street City State ZIP Relation: SS#: Employer:

ORTHODONTIC INSURANCE PRIMARY Orthodontic Coverage: YES    NO Dental Insurance Company Name: Insurance Company Address: Insurance Company Phone #: Group Number (Plan, Local, or Policy #): Insured's Name: Relation: Insured's Birthdate: Insured's SS#: Insured's Employer: SECONDARY Orthodontic Coverage: YES    NO Dental Insurance Company Name: Insurance Company Address: Insurance Company Phone #: Group Number (Plan, Local, or Policy #): Insured's Name: Relation: Insured's Birthdate: Insured's SS#: Insured's Employer:

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

MEDICAL HISTORY Do you have a personal physician?: YES    NO Physician's Name: Physician's Phone #: Date of last visit: Your current physical health is: GOOD    FAIR    POOR Are you currently under the care of a physician?: YES    NO Please explain: Are you taking any prescription / over-the-counter drugs?: YES    NO Please list each one: For Women: Are you pregnant?: YES    NO    Week#: Have you ever had any of the following diseases or medical problems? Artificial Bones/Joints: YES    NO Artificial Valves/Pacemaker: YES    NO Asthma/Arthritis: YES    NO Cancer/Chemotherapy: YES    NO Cleft Lip/Palate: YES    NO Diabetes/Tuberculosis(TB): YES    NO Difficulty Breathing: YES    NO Emphysema/Glaucoma: YES    NO Epilepsy/Seizures/Fainting Spells: YES    NO Genetic Disorders: YES    NO Glandular Disorders: YES    NO Heart Attack/Stroke: YES    NO Heart Murmur: YES    NO Hemophilia/Abnormal Bleeding: YES    NO Hepatitis: YES    NO High/Low Blood Pressure: YES    NO HIV+/AIDS: YES    NO Hospitalized for Any Reason: YES    NO Jaw Clicking/Popping: YES    NO Jaw Soreness: YES    NO Jaw Stiffness: YES    NO Kidney Problems: YES    NO Mitral Valve Prolapse: YES    NO Emotional Problems: YES    NO Rheumatic/Scarlet Fever: YES    NO Severe/Frequent Headaches: YES    NO Sleep Disorders: YES    NO Tonsils/Adenoids Removed: YES    NO Have you ever been advised by your physician to take an antibiotic prior to dental procedures? YES    NO Have you ever taken any prescribed diet medications? YES    NO Please list any serious medical condition(s) you have ever had: Are you allergic to any of the following: Aspirin: YES    NO Any Metal/Plastic: YES    NO Codeine: YES    NO Dental Anesthetics: YES    NO Erythromycin: YES    NO Latex: YES    NO Penicillin: YES    NO Tetracycline: YES    NO Other: YES    NO Please list any other drug you are allergic to:

DENTAL HISTORY What are the main concerns you would like orthodontics to accomplish? Have you ever had or been evaluated for orthodontic treatment?: YES    NO Is there or has there been a concern about periodontal (gum and bone) problems?: YES    NO Is there any UNUSUAL dental history?: YES    NO If yes, please explain: Do any speech problem exist: YES    NO Are you frightened or anxious about orthodontic treatment?: YES    NO Are you concerned about the appearance of your teeth? YES    NO What aspect of orthodontic treatment are you most concerned about? Quality          Cost Discomfort    Length of treatment Do you now or have you ever experieced pain/discomfort in your jaw joint (TMJ/TMD): YES    NO Your current dental health is: GOOD    FAIR    POOR Have you ever had an injury to your: MOUTH    TEETH    CHIN Do you generally breathe through your mouth when awake/asleep: YES    NO Have you ever had or presently have any of the following habits? Thumb Sucking: YES    NO Finger Sucking: YES    NO Tongue Thrusting: YES    NO Lip Biting: YES    NO Nail Biting: YES    NO Grinding/Clenching teeth: YES    NO Snoring: YES    NO Smoking/Tobacco Chewing: YES    NO

SIGNATURE  I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent. (you will be asked to sign this document on your first visit to our office) ______________________________________________________________ signaturedate

THANK YOU FOR FILLING OUT THIS FORM COMPLETELY This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees. One or more credit reporting service maybe used at the discretion of the office. (you will be asked to sign this document on your first visit to our office) ______________________________________________________________ signaturedate Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.