New Patient Form New Patient Form PATIENT INFORMATIONName** First Name Middle Name Last Name NicknameAge*Birth Date* Date Format: MM slash DD slash YYYY Sex*MaleFemaleAddress* Address* 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 Patient Relationship to PatientNameSex*MaleFemaleAddress Address* City* State* Zip* SSNBirth Date Date Format: MM slash DD slash YYYY CellHomeWorkEmail EmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#Relationship to Patient 2Relationship to PatientNameSex*MaleFemaleAddress Address* City* State* Zip* SSNBirth Date Date Format: MM slash DD slash YYYY CellHomeWorkEmail EmployerOccupationIf you have orthodontic insurance coverage for the patientYesNoInsurance Company NameInsurance PhoneID#Group#MEDICAL HISTORYHistory of the following: (Please check all that apply) Blood Disorder ADD/ADHD AIDS Congenital Heart Defect Cancer Hepatitis/HIV High Blood Pressure Arthritis Asthma Joint Replacements Diabetes Kidney Nervous Disorder Epilepsy Tuberculosis Heart Conditions Bone Density History of major illnessIs the patient allergic to LATEX NICKEL/METALS PLASTIC Other Sensitivities / AllergiesCurrent MedicationsDoes the patient require antibiotics before dental treatment?YesNoPuberty?YesNoHas menstruation started?YesNoDENTAL HISTORYHistory of the following: (Please check all that apply) Difficulty Chewing/Eating Clenching Snoring Lip Sucking/Biting Ear Infection Grinding Pacifier (infant) Finger/Thumb Nail Biting Soda/Juice Overconsumption Mouth Breathing Speech Tongue Thrust Sleep Apnea Pain TMJ: Jaw Popping/Locking Mouth Guard Headaches Adenoids or tonsils removed?YesNoMissing or extra permanent teeth?YesNoInjuries to the face, mouth or jaw?YesNoDiscomfort in the jaw (TMJ/TMD)?YesNoDifficulty breathing through nose?YesNoDoes the patient brush their teeth daily?YesNoFloss?YesNo