Confidential Adult Patient Health History & Information

Patient Information


Patient's Name:


Responsible Party Information

Name of person financially responsible for account:

Mailing Address:

Do you have dental insurance which covers orthodontics?:
Correspondence should be sent to:

Insurance Information

Name of insured:

Dental History

What is the main orthodontic problem as you see it?:

Are you sensitive about the appearance of your teeth?:

Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.):

What do you consider the main benefits of orthodontic treatment?:


How do you feel about wearing braces?:

Have you ever had an orthodontic consultation?:
What would you like orthodontic treatment to accomplish?:
Are you interested in:
Name of your general dentist:
Frequency of dental check-ups:

Answer yes if applicable now or in the past:

Yes - Apprehensive about dental care
Yes - Discomfort from teeth
Yes - Previous orthodontic therapy
Yes - Teeth that are shifting
Yes - Frequent canker sores
Yes - Thumb/finger sucking as a child
Yes - Fluoride treatments
Yes - Any injuries to face, mouth, teeth
Yes - Speech therapy
Yes - Injury involving teeth
Yes - Injury to either jaw
Yes - Frequent clenching of teeth
Yes - Grinding of teeth
Yes - Wake up with sore teeth
Yes - Wake up with sore jaw
Yes - Jaw joint sounds
Yes - Jaw joint pain
Yes - Jaw “tires” when eating
Yes - Jaw catches when opening
Yes - Jaw locks in closed position
Yes - Jaw locks in open position
Yes - Facial pain
Yes - Frequent headaches
Yes - Neck or shoulder pain
Yes - Tonsils/Adenoids removed
Yes - Any missing permanent teeth
Yes - Any discomfort from gums
Yes - Requires premedication

What is the main orthodontic problem as you see it?:

Does any genetically related family member have a similar facial/dental appearance?:

Dental History

Are you currently in good physical health?

Answer yes if applicable now or in the past:

Yes - Allergic to latex
Yes - Allergic to metals
Yes - Anemia/Radiation treatment
Yes - Arthritis
Yes - Asthma
Yes - Congenital heart defect
Yes - Diabetes
Yes - Ever been hospitalized
Yes - Heart attack/Stroke
Yes - Heart murmur
Yes - Hepatitis
Yes - Hormone therapy
Yes - Mouth breathing
Yes - Prolonged bleeding
Yes - Psychological counseling
Yes - Rheumatic fever
Yes - Seizures/Epilepsy
Yes - Taking medications
Yes - Tuberculosis
Yes - Drug allergies
Yes - Requires premedication

If you checked yes to any of the above, please explain:

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.