New Patient Information

How were you referred to Chapman Orthodontics?

Parent's Marital Status

Do you have legal custody of the patient?

Who is responsible for making appointments?

Has an orthodontist been consulted previously for this concern?

Who first noticed the need for orthodontic treatment?

Is the patient concerned about the appearance of his/her teeth?

Has the patient had any orthodontic treatment in the past?

Has any member of the family had orthodontic treatment in the past?

Does any member of the family or close relative have a similar arrangement of the teeth or jaw?

Does the patient have interest in

Is the patient interested in orthodontic treatment for

Is the general attitude toward wearing orthodontic appliances one of ?

Has the patient been under the care of a physician in the past 2 years? If yes, state illness and duration.

Is the patient currently taking any medication(s)? If yes, which ones?

Does the patient have any disease, condition, or problem not listed? If yes, please list below.

Does the patient have a tendency for colds, cold sores or ear infections?

Has the patients tonsils and/or adenoids been removed? If yes, what age?

Does the patient require premedication for dental procedures?

Is the patient pregnant now?

Does the patient anticipate becoming pregnant soon?

Has the patient been informed of any missing or extra permanent teeth?

Has the patient ever had operations or injuries of the head or neck?

Has the patient ever received a severe blow to the teeth or jaws? If yes, what age?

Does the patient have sore or bleeding gums?

Has the patient had any permanent teeth removed?

Has the patient ever experienced or is currently experiencing any problems with the jaw joints? If yes, please explain

Does the patient play a musical instrument? If yes, what kind?