First Name	MI	Last

Sex	Birth Date	Age

Address	City	State	Zip Code

Responsible Party Information:
Father, Self or Guardian Information

First Name	MI	Last

Sex	Birth Date	Age	Marital Status

Address	City	State	Zip Code

Home Phone #	Work Phone #

Driver's License #	Social Security #

How Long at this Address?	How Long at Previous Address?

Email Address

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Patient Information - Responsible Party Information
Mother or Spouse Information

First Name	MI	Last

Sex	Birth Date	Age	Marital Status

Address	City	State	Zip Code

Home Phone #	Work Phone #

Driver's License #	Social Security #

How Long at this Address?	How Long at Previous Address?

Email Address

Other Information

Who is the Responsible Party?	Dentist Name	Physician Name

Who Referred You?	School Name	Grade

Sports or Hobbies	Other Children - Name & Age

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Medical Information

Yes	No	Description		Yes	No	Description
		Any Heart Disease				Rheumatic/Yellow/Scarlet Fever
		Any Respiratory Disease				Acquired Immune Deficiency Syn.
		Any Blood Disease				Is Patient Under Medical Care
		Any Broken Bones				Any History of Fainting or Dizziness
		Any Thyroid Disease				Any Nervous/Emotional Problems
		Any Kidney Disease				Does the Patient Smoke
		HIV Positive				Any Drug Addiction
		Any Venereal Disease				Is the Patient Pregnant
		Any Intestinal Disease				Measles/Mumps/Chicken Pox
		Any Bone Disease				Is the Patient in Good Health
		Allergic to Anything				Any High/Low Blood Pressure
		Any Endocrine Problems				Is Height & Width Normal for Age
		Any Prolonged Bleeding				Any Problems w/ Wounds Healing
		Had a Physical this Year				Has the Patient Reached Puberty

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Dental History

Yes	No	Description		Yes	No	Description
		Has the Patient Seen a General Dentist in the Last Year				Cheek, Tongue or Lip Chewing
		Any Pain, Clicking or Discomfort in or Near the Ears				Thumb Sucking
		Has the Mouth, Face or Teeth Been Injured by a Fall or Accident				Mouth Breathing
		Are You Aware of Any "Gum" Problems				Finger Nail Biting
		Have the Patient's Tonsils or Adenoids Been Removed				Clenching Teeth
		Do You Feel the Patient can Benefit from Orthodontic Treatment				Tongue Thrusting
		Is the Patient Happy with Their "SMILE"				Grinding Teeth
		Does the Patient Want to Improve Their "SMILE"				Speech Problems
		Would the Patient Mind Wearing "BRACES"				Has the Patient Been Examined by an Orthodontist Before
				When:
In Your Own Words What is the Orthodontic Problem?				What Would You Like Orthodontic Treatment to Accomplish?

Please print out pages and bring with you to the office on your first visit, or drop in the mail to us at:

DICKERSON ORTHODONTICS
1200 W. Warner Rd. Ste. 1
Chandler, AZ 85224

Thank you!

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