Date of Last Visit
Street Address Line 2
State / Province
Postal / Zip Code
Please select yes or no (if yes, please specify)
Are you taking any medications (including for osteoarthritis)?
Please list any medications you are taking
Are you allergic to any medications?
Please list medicines you are allergic to
Do you have any other allergies? (latex, nickel, metal)
Please list other allergies
Do you have a history of a major illness?
Please list major illness(es) you've had
Have you had any major operations?
Please list major operation(s) you've had
Have you ever been involved in a serious accident?
Please list serious accident(s) you've had
Please check any of the medical conditions below that you have had or currently have:
Congenital Heart Defect
High Blood Pressure
Tumor or Cancer
Eye or Ear Problems
Do you require antibiotics prior to any dental treatment?
Are there any medical conditions that you would like to discuss with the Doctor in private?
Date of Last Visit
What are your orthodontic concerns?
How do you feel about receiving orthodontic treatment?
Please check accordingly
Has anyone in your family received orthodontic treatment?
Have you ever seen an orthodontist before?
Have you always had a favorable dental experience?
Are you presently in any dental pain?
Have you ever had any teeth removed?
Do you have any congenitally missing teeth?
Do you have extra teeth?
Have you ever lost or chipped any teeth?
Have you had your tonsils or adenoids removed?
Have there been any injuries to the face, mouth, or teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any thumb or finger sucking habits?
Do you have a tongue thrust?
Are you a mouth breather?
Do you snore?
Do your teeth or jaws ever feel uncomfortable when you wake up in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of your clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have tension headaches?
How did your family feel about the result of their orthodontic treatment?
Previous Orthodontist Name
Date you last visited an orthodontist
Please specify any injuries in your face, mouth, or teeth.
Are you pregnant?
Has menstruation started?
Please verify that you are human
Should be Empty: