Patient Forms Please help us be prepared for your first appointment by completing this Patient Information and Medical History. Adolescent Patient Information First Name:  Middle Name:  Last Name:  Nickname:  Address:  City:  State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:  Phone:  Birthday:  Height:  Weight:  Age:  Sex:  Male Female   Adult Patient Information   FATHER or SELF or GUARDIAN INFORMATION First Name:  Middle Name:  Last Name:  Nickname:  Address:  City:  State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:  Phone:  Birthday:  Height:  Weight:  Age:  Sex:  Male Female Marital Status:  Driver's License #:  Social Security #:  How Long at This Address:  How Long at Previous Address:    Employer / Insurance Information Employer Name:  Employer Address:  Employer City:  Employer State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employer Zip:  Number of Years Employed:  Occupation:  Orthodontic Coverage:  Yes No Insurance Co. Name:  Insurance Address:  Insurance City:  Insurance State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Insurance Zip:  Insurance Phone:  Ext:  Group #:  Local or Union #:  MOTHER or SPOUSE INFORMATION First Name:  Middle Name:  Last Name:  Nickname:  Address:  City:  State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip:  Phone:  Birthday:  Height:  Weight:  Age:  Sex:  Male Female Marital Status:  Driver's License #:  Social Security #:  How Long at This Address:  How Long at Previous Address:    Employer / Insurance Information Employer Name:  Employer Address:  Employer City:  Employer State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employer Zip:  Number of Years Employed:  Occupation:  Orthodontic Coverage:  Yes No Insurance Co. Name:  Insurance Address:  Insurance City:  Insurance State:  Select your state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Lousiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Insurance Zip:  Insurance Phone:  Ext:  Group #:  Local or Union #:  Other Information Who is the Responsible Party:  Dentist Name:  Address:  Physician Name:  Address:  Who May We Thank For Referring You:  Sports or Hobbies:  School Name:  Grade:  Number of Brothers:  Ages:  Number of Sisters:  Ages:  MEDICAL INFORMATION Frequent or Severe Headaches:  Yes No Any Heart Disease:  Yes No Any Sinus or Respiratory Disease:  Yes No Any Blood Disease:  Yes No Any Liver Disease:  Yes No Any Throid Disease:  Yes No HIV Positive:  Yes No Any Venereal Disease:  Yes No Any Intestinal Disease:  Yes No Any Bone Disease:  Yes No Any Nervous/Emotional Problems:  Yes No Any High or Low Blood Pressure:  Yes No Any Endocrine Problems:  Yes No Any Problems with Wounds Healing:  Yes No Any Tumors or Cancer:  Yes No Tonsilitis/Frequent Sore Throats:  Yes No Any Joint Problems:  Yes No Rheumatic/Yellow/Scarlet Fever:  Yes No Acquired Immune Deficiency Syndrome:  Yes No Is Patient Under Medical Care:  Yes No Rheumatism or Arthiritis:  Yes No Is the Patient Taking any Medications:  Yes No A History Of Fainting or Dizziness:  Yes No Does The Patient Have a Drug Addiction:  Yes No Is The Patient Pregnant At This Time:  Yes No Measles/Mumps/Chicken Pox:  Yes No Does The Patient Smoke:  Yes No Has The Patient Ever Had Fever Blisters:  Yes No Is Height & Weight Normal For Age:  Yes No Is The Patient In Good Health:  Yes No Has The Patient Had a Physical This Year:  Yes No Has The Patient Reached Puberty:  Yes No If Male, Begun To Shave:  Yes No If Female, Begun To Menstruate:  Yes No Heart Murmur:  Yes No Mononucleosis:  Yes No Hepatitis:  Yes No Polio:  Yes No Diabetes:  Yes No Anemia:  Yes No Hemophilia:  Yes No Emphysema:  Yes No Epilepsy:  Yes No Asthma or Hay Fever:  Yes No Tuberculosis:  Yes No Any Broken Bones:  Yes No Prolonged Bleeding:  Yes No Yellow Jaundice:  Yes No Radiation Therapy:  Yes No Chemical Therapy:  Yes No Blood Transfusion:  Yes No Latex Allergy:  Yes No Is The Patient Allergic To Anything:  Yes No If Yes, What :  Is there any disease or condition you would like to  discuss with the doctor in prviate:  Yes No Any Unusual Reactions to Any Of The Following:  Aspirin Sulfa Drugs Penicillin Barbiturates Other Medications Please Explain:  List Any Medications Currently Taking:  DENTAL HISTORY Has The Patient Seen a General Dentist In The Last  Year:  Yes No Any Pain, Clicking or Discomfort in or Near The Ears:  Yes No Has The Mouth, Face or Teeth Been Injured by a Fall or Accident:  Yes No Have You Been Informed of Missing or Extra  Permanent Teeth :  Yes No Are You Aware Of Any Gum Problems:  Yes No Have The Patient's Tonsils or Adenoids Removed:  Yes No Do You Feel The Patient Can Benefit From Orthodontic  Treatment:  Yes No Is The Patient Happy with Their "SMILE":  Yes No Does The Patint Want To Improve Their "SMILE" and "BITE":  Yes No Would The Patient Mind Wearing "BRACES":  Yes No   When Are The Patient's Teeth Brushed After Breakfast:  Yes No After Lunch :  Yes No After Dinner :  Yes No Before Bed :  Yes No   Does The Patient Have or Ever Had The Following Habits Before Cheek, Tongue or Lip Chewing:  Yes No Thumb Sucking:  Yes No Mouth Breathing:  Yes No Finger Nail Biting:  Yes No Clenching Teeth:  Yes No Tongue Thrusting:  Yes No Grind Teeth:  Yes No Speech Problems:  Yes No Is The Patient Pregnant At This Time:  Yes No Has The Patient Been Examined By An Orthodontist  Before:  Yes No If Yes, When:  Have Other Members Of The Family Had Orthodontic  Treatment:  Yes No If Yes, Were You Happy With The Results:  Yes No If No, Why:  Patient's Attitude Towards Braces:  Eagerness Willingness Complacency Antagonism Who First Noticed The Orthodontic Problem:  Parent Dentist Patient Other In Your Own Words, What Is The Orthodontic Problem:  What Would You Like Orthodontic Treatment To Accomplish:  I understand that when appropriate, credit bureau reports may be obtained. Payments are due at the time of service unless other arrangements have been made. If a statement is sent, payments must be received in the office by the 10th of the month to avoid a late charge.   Home | About Our Practice | Meet Dr. Williamson | Who Needs Orthodontics? The Magic of Braces | Life with Braces | SureSmile® | Our Offices and Contacts Patient Forms | Patient Care Video | Orthodontic Links | Play Some Games