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

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)

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?

Chapman Orthodontics

8852 West 38th Avenue | Wheat Ridge, Colorado 80033
303.421.9814

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