PATIENT & FAMILY HISTORIES

Today’ Date

Sex: M / F

1. Patient Name (Last) (First) Middle

2. Residence Address City State Zip

3. Res. Phone School Grade

4. Date of Birth Age: Years Months

5. Name of Employer Occupation
   
   Bus. Address City State Zip
   
   Bus. Phone Social Security Number

6. Name of Spouse DOB Occupation
   
   Social Security Number
   
   Address Employed By
   
   City State Zip Bus. Address
   
   
   Bus. Phone

7. Patient is: Married Separated Divorced Widowed Single

8. Who referred you to our office?

9. Do you have insurance that provides for orthodontic care? If so, please state Insurance Co. and insurance
   numbers

10. Persons responsible for account
    
    Billing Address

11. Who is the insured? Patient Spouse

DENTAL

1. Does patient have a regular dentist? Yes No
   
   If yes, is he/she your family dentist a specialist
   
   Please give name and address
   
   

2. When did you last receive dental care?

3. How frequently do you brush your teeth? Use dental floss

4. Have your teeth or either of your jaws been injured? How old was the patient?

5. Have you been informed of any missing or extra permanent teeth?

6. Do you have any jaw, joint or facial pain?

7. Do you have or ever had any of the following habits?
   
   lip sucking thumb sucking lip biting constant mouth breathing
   
   nail biting tongue thrusting grinding no oral habits

8. Do you have any speech problems?

9. Please describe the orthodontic problem as you see it

10. Describe anyone in your family with a similar dental or facial condition

11. Has anyone else in the family received orthodontic care?

12. Has an orthodontist been consulted previously?

MEDICAL

1. Are you in good health? Yes No

2. Describe any major illness
   
   
   

3. Physician’s name and address
   
   
   

4. Check any of the following for which you have been treated:
   
   
   

Diabetes	Tuberculosis	Endocrine Problems
Pneumonia	Anemia	Prolonged Bleeding
Heart Trouble	Epilepsy	Fainting/Dizziness
Rheumatic Fever	Asthma	Nervous Disorders
Bone Disorders	Kidney Involvement	Liver Involvement - Hepatitis

5. Do you have a tendency to colds? Sore throat? Ear infections?

6. Have tonsils been removed? Age Adenoids? Age

7. List any drugs or medications now being taken. Give reasons:
   
   
   
   

8. List any allergies or drug sensitivity:

9. Height Weight

10. Women: Are you pregnant? Yes No

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I certify that the above information is correct to the best of my knowledge. I will not hold my
doctor or any staff responsible for any errors or omission that I may have made in the
completion of this form.

Signature Date

Reviewed by Date

OFFICE USE ONLY

Diagnosis

1. Alignment

2. Profile

3. Sagital

4. Transverse

5. Vertical

6. Other

7. C.C.