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Does the patient have insurance coverage for orthodontic treatment?

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Presently under physician's care during the past two years other than routine exams?
Presently taking any medications?
Congenital anomalies (birth defects)?
Has the patient had a history of any of the following?
Has the patient had any serious illness, operation, or been hospitalized within the past 5 years?
Respiratory History: Do you:
Have allergies to:
Seasonal Grasses




Snore when sleeping?
Breathe through mouth?
Have frequent colds?
Have frequent stuffy nose?
Have frequent sore throat or tonsillitis?
Have chewing or swallowing difficulty?
Have frequent ear infections?
Has the patient recieved medical treatment from an allegist or ear, nose and throat specialist?
If Yes, please specify:
Has the patient had their adenoids removed?
Has the patient had their tonsils removed?
Has the patient received or been requested to receive speech correction?
Does the patient have pain or clicking in the jaw joints?
Does the patient have frequent headaches?
Have any teeth been injured due to accidents or blows to the mouth?
Please provide information as it pertains to the patient regarding the following habits:
Grinding of teeth
Tongue thrusting
Nail biting
Lip biting or sucking
Has the patient had any unusual dental experiences?
Has the patient had any previous orthodontic consultations?
Or treatment?
Orthodontic consultation prompted by:
Patient's Interest in orthodontic treatment:
Have any family members been examined or treated in our office?
Growth Information
Has the patient shown signs of increased growth recently?
Female: Age of first monthly period:
Female: Are you pregnant now?

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsiblity to inform this office of any changes in my medical status.