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Get a smile you can celebrate...
Celebrate a beautiful, healthy smile...
Smile, it’s contagious...
It’s more than just braces...
Get a smile you can celebrate...
Celebrate a beautiful, healthy smile...
Smile, it’s contagious...
New Patient Information
Patient Name *
Preferred
DOB
Gender
M
F
Address
Home #
Cell #
Work #
Email
Responsible Party
Relationship to Patient
How were you referred to Chapman Orthodontics?
Dentist
Family/Friend
Google/NextDoor.com
AlignTech
Other
(Other)
*(For patients 18 years and younger)
Mother's Information
Stepmother
Guardian
Name
Cell #
home #
Work #
Email
Father's Information
Stepfather
Guardian
Name
Cell #
home #
Work #
Email
Parent's Marital Status
Single
Married
Divorced
Widowed
Seperated
Who is accompanying the patient today?
Relation
Do you have legal custody of the patient?
Yes
No
Who is responsible for making appointments?
Mother
Father
Other
(Other Name)
Dental Insurance
Primary Dental Insurance
Ortho Coverage
Yes
No
Subscriber Name
Subscriber DOB
Subscriber Employer
Insurance Company
Phone #
Insurance Company Address
SSN of Subscriber
Group #
Secondary Dental Insurance
Ortho Coverage
Yes
No
Subscriber Name
Subscriber DOB
Subscriber Employer
Insurance Company
Phone #
Insurance Company Address
SSN of Subscriber
Group #
General Dentist Name
Date of Last Visit
Are there any specific concerns/comments from the general dentist or yourself about the patient's teeth?
Has an orthodontist been consulted previously for this concern?
Yes
No
Who first noticed the need for orthodontic treatment?
Patient
Parent/Family Member/Friend
Dentist
Is the patient concerned about the appearance of his/her teeth?
Yes
No
Has the patient had any orthodontic treatment in the past?
Yes
No
Has any member of the family had orthodontic treatment in the past?
Yes
No
Does any member of the family or close relative have a similar arrangement of the teeth or jaw?
Yes
No
Does the patient have interest in
Braces
Invisalign
Is the patient interested in orthodontic treatment for
Improved Appearance
Improved Speech
Improved Bite Function
Is the general attitude toward wearing orthodontic appliances one of ?
Eagerness
Neutral
Antagonism
Medical History
Has the patient been under the care of a physician in the past 2 years? If yes, state illness and duration.
Yes
No
(If yes)
Is the patient currently taking any medication(s)? If yes, which ones?
Yes
No
(Medications)
Has the patient ever had
Diabetes
High Blood Pressure
Rheumatic Fever
Anemia
Liver Disease
Prolonged Bleeding
Fainting or Dizziness
Psychiatric Treatment
Asthma
Sinus Trouble
Chemotherapy
Ulcers
Mitral Valve Prolapse
Stroke
Heart Disease
Heart Murmur
Nervous Disorder
Arthritis
Blood Transfusion
Epilepsy & Seizures
Kidney Trouble
Tuberculosis (T.B.)
Hay Fever
Allergies
Does the patient have any disease, condition, or problem not listed? If yes, please list below.
Yes
No
(If yes)
Does the patient have or ever been exposed to individuals with
Hepatitis
Acquired immune deficiency syndrome (AIDS/HIV+)
Does the patient have a tendency for colds, cold sores or ear infections?
Yes
No
Has the patients tonsils and/or adenoids been removed? If yes, what age?
Yes
No
(If yes)
Does the patient require premedication for dental procedures?
Yes
No
Female Patients Only
Is the patient pregnant now?
Yes
No
Does the patient anticipate becoming pregnant soon?
Yes
No
Dental History
Has the patient been informed of any missing or extra permanent teeth?
Yes
No
Has the patient ever had operations or injuries of the head or neck?
Yes
No
Has the patient ever received a severe blow to the teeth or jaws? If yes, what age?
Yes
No
(If yes)
Does the patient have sore or bleeding gums?
Yes
No
Has the patient had any permanent teeth removed?
Yes
No
How many times a day does the patient brush his/her teeth?
Has the patient ever had
Thumb/Finger Sucking
Lip Sucking/Biting
Clenching/Grinding Teeth
Mouth Breather
Speech Problems
Nail Biting
Has the patient ever experienced or is currently experiencing any problems with the jaw joints? If yes, please explain
Yes
No
(If yes)
Additional Patient Information
Does the patient play a musical instrument? If yes, what kind?
Yes
No
(If yes)
Patient’s Hobbies
*(For patients 18 years or younger
Present Height
Present Weight
Father’s Height
Mother’s Height
Has he/she started to grow quickly?
Yes
No
Has growth changed over the past few months?
Yes
No
Male Patients Only
Has his voice changed recently?
Yes
No
Has he started to shave?
Yes
No
Female Patients Only
Has she started her monthly period?
Yes
No
At what age did her mother or sisters start?
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