Patient InformationPatient Name* First Last Gender Male FemaleBirth Date MM slash DD slash YYYY AgeHome Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP SchoolGradeList any sports or extracurricular activitiesSiblings (names and ages)Parent/Guardian InformationParent/Guardian 1Parent Marital StatusSingleMarriedDivorcedWidowedSignificant OtherRelationship to PatientN/AMotherStep-MotherFatherStep-FatherGuardianOtherName First Last Email Address Birth Date MM slash DD slash YYYY Driver's License NumberAddress (if different than child's) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Primary PhonePhone TypeHomeCellSecondary PhonePhone TypeHomeCellEmployerOccupationParent/Guardian 2Parent Marital StatusSingleMarriedDivorcedWidowedSignificant OtherRelationship to PatientN/AMotherStep-MotherFatherStep-FatherGuardianOtherName First Last Email Address Birth Date MM slash DD slash YYYY Driver's License NumberAddress (if different than child's) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Primary PhonePhone TypeHomeCellSecondary PhonePhone TypeHomeCellEmployerOccupationEmergency ContactEmergency Contact Name (other than parent) First Last PhoneRelation to ChildAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Person(s) OK to release appointment or medically related information to concerning child. List relation to child.Insurance InformationPrimary InsurancePrimary Insurance CompanyPhone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's Name First Last RelationBirth Date MM slash DD slash YYYY EmployerWork Phone NumberCo-pay (if known)Deductible (if known)Secondary InsuranceSecondary Insurance CompanyPhone NumberGroup NumberPolicy NumberMember ID NumberPolicy Holder's Name First Last RelationBirth Date MM slash DD slash YYYY EmployerWork Phone NumberCo-pay (if known)Deductible (if known)Dental HistoryGeneral DentistLast VisitHow did you hear about our practice?AdInternetFamily or FriendPhysicianOtherName of person referringWhat are the main concerns you would like orthodontics to accomplish?Has your child visited an orthodontist before?YesNoWhen and for what reason?Has your child's tonsils or adenoids been removed?YesNoHas your child ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNoDoes your child you have any missing or extra permanent teeth?YesNoHas your child ever had an injury to (select all that apply): Teeth Mouth ChinDoes your child have speech problems?YesNoWhat kind of speech problems?Does your child currently or has your child ever had any of the following habits? Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/ Finger Sucking Chewing/Eating ProblemsMedical HistoryIs your child currently being treated by a physician?YesNoReasonPhysicianPhone NumberDoes your child have any allergies/sensitivities to medications or latex?YesNoList allergiesIs your child currently taking any prescription or over-the-counter medications?YesNoPlease list, with dosage:Has puberty and/or menstruation begun?YesNoHas your child ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of lonimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)?YesNoHas your child had any serious illnesses or operations?YesNoDescribe:Has your child ever had a blood transfusion?YesNoGive approximate dates:Is your child pregnant?YesNoIs your child nursing?YesNoIs your child taking birth control?YesNoCheck if your child has or have ever had any of the following: Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal DiseaseI 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 the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.Patient Signature and/or Responsible Party First Last Date MM slash DD slash YYYY
