New Patient Form "*" indicates required fields Patient InformationName* First Middle Last Residence Street City State Zip Code Home Phone*Cell Phone*Work PhoneBirthdate* MM slash DD slash YYYY Social Security#*Email* Marital Status*SingleMarriedWidowedSeparatedDivorcedEmployerOccupationNo. of years employedWhom may we thank for referring you to our officeDental Insurance InformationInsurance CompanyInsurance PhoneSubscriber NameSubscriber Birthdate MM slash DD slash YYYY Member IDGroup NumberDo you have dual coverage?* Yes No If yes, please fill the following information:Insurance CompanyInsurance PhoneSubscriber NameSubscriber Birthdate MM slash DD slash YYYY Member IDGroup NumberEmergency InformationName*Phone*Relationship*Medical HistoryPhysician*Date of Last Visit MM slash DD slash YYYY Address*Phone*Are you taking any medication?* Yes No Please mention:Are you allergic to any medication?* Yes No Please mention:Do you have a history of a major illness?* Yes No Please mention:Have you had any operations?* Yes No Please mention:Have you ever been involved in a serious accident?* Yes No Please mention:Have you ever smoked or chewed tobacco?* Yes No Have seen a physician in the last 12 months?* Yes No Why?Female Patients only:Are you pregnant? Yes No Has menstruation started? Yes No Are you taking Birth Control? Yes No Patients up to 12 years of age only:Is Your child often irritated or angry during the day? Yes No Is your child’s weight above the 90% for their age group? Yes No Does your child loudly snore? Yes No Does your child sometimes have labored breathing at night? Yes No Have you ever noticed your child stop breathing at night? Yes No Does your child have enlarged tonsils and/or adenoids? Yes No Does your child have problems with concentration? Yes No Does your child often yawn, or is tired or sleepy during the day? Yes No Check any of the medical conditions below that you have had or currently have.* Abnormal Bleeding Hemophilia Diabetes Hepatitis Liver problems Pneumonia Anemia Dizziness Herpes Arthritis Epilepsy High Blood Pressure Radiation/Chemotherapy Asthma or Hay fever Gastrointestinal Disorders HIV / Aids Rheumatic Fever Bone Disorders Heart Problems Kidney problems Tuberculosis Congenital Heart Defect Heart Murmur Nervous Disorders Tumor or Cancer Are there any medical conditions we have not discussed that you feel we should be aware of? Dental HistoryGeneral DentistDate of last visit MM slash DD slash YYYY What concerns you most about your teeth?Are you presently in any dental pain? Yes No Have you ever experienced any unfavorable reaction to dentistry? Yes No Have your wisdom teeth been removed? Yes No Have you ever lost or chipped any teeth? Yes No Have there been any injuries to face, mouth, or teeth? Yes No Is any part of your mouth sensitive to temperature? Yes No Where?Is any part of your mouth sensitive to pressure? Yes No Where?Do your gums bleed when you brush? Yes No Do you have any type of thumb or tongue habit? Yes No Are you a mouth breather? Yes No Have you ever seen an orthodontist? Yes No If yes, who and when?What is your attitude toward receiving orthodontic treatment? Yes No Has anyone in your family received orthodontic treatment? Yes No Do your teeth or jaws ever feel uncomfortable when you awake in the morning? Yes No Are you aware of your jaw clicking or popping? Yes No Are you aware of clenching your teeth during the day? Yes No Have you ever been told that you grind your teeth? Yes No Do you have “tension” headaches? Yes No Have you ever experienced chronic ringing in your ears? Yes No Are you aware that some appointments will be during work hours? Yes No Consent1* I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Sepi Torkan to perform a complete orthodontic evaluation.*SignatureDate MM slash DD slash YYYY Δ