New Patient Form PATIENT INFORMATIONFirst Name*Middle NameLast Name*NicknameAge*Birth Date*Sex*MaleFemaleAddress*City*State*Zip*Cell*HomeEmail*SchoolGradeHobbies/SportsEmployerOccupationHow Long?GENERAL INFORMATIONHow did you hear of Heidi Harman Orthodontics?Has the patient had prior orthodontic treatment or exam?Where/When?General DentistPhoneLast VisitChildren/Siblings (Ages)RESPONSIBLE PARTY INFORMATIONMarital StatusSingleMarriedPartneredWidowedDivorcedSeparatedRelationship to PatientNameSexMFAddressCityStateZipSSNBirth DateCellHomeWorkEmailEmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#Relationship to PatientNameSexMFAddressCityStateZipSSNBirth DateCellHomeWorkEmailEmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#MEDICAL HISTORYHistory of the following: (Please check all that apply)Blood DisorderADD/ADHDAIDSCongenital Heart DefectCancerHepatitis/HIVHigh Blood PressureArthritisAsthmaJoint ReplacementsDiabetesKidneyNervous DisorderEpilepsyTuberculosisHeart ConditionsBone DensityHistory of major illnessIs the patient allergic toLATEXNICKEL/METALSPLASTICOther Sensitivities / AllergiesCurrent MedicationsDoes the patient require antibiotics before dental treatment?YNPuberty?YNHas menstruation started?YNDENTAL HISTORYHistory of the following: (Please check all that apply)Difficulty Chewing/EatingClenchingSnoringLip Sucking/BitingEar InfectionGrindingPacifier (infant)Finger/ThumbNail BitingSoda/Juice OverconsumptionMouth BreathingSpeechTongue ThrustSleep ApneaPainTMJ: Jaw Popping/LockingMouth GuardHeadachesAdenoids or tonsils removed?YNMissing or extra permanent teeth?YNInjuries to the face, mouth or jaw?YNDiscomfort in the jaw (TMJ/TMD)?YNDifficulty breathing through nose?YNDoes the patient brush their teeth daily?YNFloss?YNSendThis field should be left blank