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Date_____________ PATIENT INFORMATION Patient’s Full name______________________________________ Date of Birth____________ Age_________ Sex_______ Address____________________________________________City/State___________________________Zip Code_______________ Home Phone #_________________________________ Cell Phone # _____________________________ SSN______-_____-_______ Email___________________________________________ Names of friends of relative who were former patients_______________________________________________________________ Who may we thank for referring you to our office? __________________________________________________________________ Patient’s Dentist_____________________________________ Patient’s Physician__________________________________________ INSURANCE INFORMATION Do you have Orthodontic Insurance? YES NO If yes, please complete the following: Insured’s Name_______________________________ Date of Birth________________ Insured’s Social Security #____-___-_____ Insurance Company___________________________________ Group #___________________ Local #_______________________ Insurance Company Address___________________________________________________________________________________ Insurance Company Phone #______________________________Insured’s Employer_____________________________________ Do you have dual coverage? YES NO If yes, please complete the following: Insured’s Name_____________________________________ Date of Birth____________ Insured’s Social Security #____-___-_____ Insurance Company__________________________________ Group #___________________ Local #_________________________ Insurance Company Address____________________________________________________________________________________ Insurance Company Phone #________________________________Insured’s Employer____________________________________ DENTAL HISTORY Does patient receive regular dental checkups? YES NO Last dental exam__________________________________ Last Dental X-rays___________________________________________ Has patient received any previous orthodontic consultation or treatment? ______________________________________________ How often does patient brush his/her teeth? ____________________ Is floss used?________________ How often? _____________ Does the patient currently have, or has the patient ever had any of the following? Y N Periodontal disease Y N Gum surgery Y N Root canals, crowns or bridges Y N Any clicking, popping or pain of jaw, joints (TMJ) Y N Any missing or extra teeth Y N Trouble chewing Y N Any past facial or mouth injuries? What? ____________________________________________________ What are you or your dentist most concerned about? (Purpose of visit)__________________________________________________ ORAL HISTORY The following are some habits commonly found which may influence tooth position. Last info as pertains to patient: Y N Thumb sucking/until age________ Y N Finger sucking/ until age_________ Y N Nail biting Y N Mouth Breather Y N Grinding of Teeth Other habits________________________________________________________________________________________________ Has patient ever had any speech therapy? ________________________________________________________________________ List any musical instruments played_____________________________________________________________________________ HEALTH HISTORY Has patient been under the care of a physical during the past two years? (Other than routine checks) Y N If yes, what for? ______________________________________________________________________________________________ Is patient currently taking medications? ___________________________________________________________________________ Is patient allergic to anything (drugs, food, pollen, ect.)_______________________________________________________________ Does the patient currently have, or has the patient ever had any of the following? Y Y Y Y Y Y Y N N N N N N N Tonsils Removed Adenoids removed Heart problems Diabetes Anemia Pneumonia Hepatitis Y Y Y Y Y Y Y N N N N N N N Epilepsy/Seizures Asthma Bleeding problems High Blood Pressure Immune Disorders Lung Problems Tuberculosis Have you been diagnosed or treated for osteoporosis? If yes, have you ever taken or are you currently taking (circle): Fosamax Didronel Boniva Y Actonel Y Y Y Y Y Y N N N N N N Nasal airway problems Sinus problems Speech problems Arthritis Tobacco usage Respiratory problems N Reclast or a generic form of Bisphophonates Does the patient have any special problems not listed above? ________________________________________________________ EMERGENCY INFORMATION Name of emergency contact person______________________________________________________________________________ Relation_________________________________ Phone #____________________________________