New Patient Information

How were you referred to Chapman Orthodontics?
*(For patients 18 years and younger)
Mother's Information
Father's Information
Parent's Marital Status
Do you have legal custody of the patient?
Who is responsible for making appointments?
Dental Insurance
Primary Dental Insurance
Ortho Coverage
Secondary Dental Insurance
Ortho Coverage
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 ?
Medical History
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?
Has the patient ever had
Does the patient have any disease, condition, or problem not listed? If yes, please list below.
Does the patient have or ever been exposed to individuals with
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?
Female Patients Only
Is the patient pregnant now?
Does the patient anticipate becoming pregnant soon?
Dental History
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 had
Has the patient ever experienced or is currently experiencing any problems with the jaw joints? If yes, please explain
Additional Patient Information
Does the patient play a musical instrument? If yes, what kind?
*(For patients 18 years or younger
Has he/she started to grow quickly?
Has growth changed over the past few months?
Male Patients Only
Has his voice changed recently?
Has he started to shave?
Female Patients Only
Has she started her monthly period?


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