PATIENT INFORMATION

* Patient First Name:
* Patient Last Name:
* Patient Birthdate:
* Primary Phone Number:
* Email Address:

DENTAL HISTORY

Patient Dental Hygiene (please check all that apply):
* Has the patient ever received an injury to the face, mouth, teeth, chin or jaw?
If yes, please describe:
* Has the patient ever had any pain, tenderness, clicking, and/or locking in the jaw?
If yes, please describe:
* Has the patient been informed about any MISSING permanent teeth?
* Has the patient been informed about any EXTRA permanent teeth?
* Have periodontal (gum) treatments or surgeries ever been recommended to the patient?

MEDICAL HISTORY

* Current Physical Health:
* Does the patient frequently take any medications for pain relief, such as Advil, Aspirin, Excedrin, Motrin, Ibuprofen, etc.? Depending on frequency, these medications may slow down tooth movement.
If yes, please list:
* Has the patient ever taken a bisphosphonate? This would include any medication used to make bones stronger, such as Bonivia, Actonel, or Fosamax. These medications may make tooth movement difficult.
If yes, please list:
FEMALES: Does the patient have any reason to believe that they may be pregnant?
Has the patient experienced or currently have any of the following medical conditions? Please check all that apply:
Please describe any additional medical conditions the patient has experienced:
* Is the patient currently under the care of a physician for any of the above medical conditions?
If yes, please list:
Does the patient have any allergies? Please check all that apply:

I affirm that the information I have provided about the patient is correct to the best of my knowledge. I understand that it is my responsibility to inform the orthodontist of any future changes or updates regarding patient's medical status.

* E-Signature/Your First and Last Name:
* Relationship to Patient: