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Gender
Marital Status
Are you aware that some appointments will be during school/work hours
Responsible Party Marital Status
Dual Coverage
Have you had previous orthodontic treatment
Do your teeth or jaws ever feel uncomfortable when you wake up in the morning
Has anyone in your family received orthodontic treatment? How did they feel about the result
Please mark any of the medical conditions you have had or currently have:
Are you presently in any dental pain
Have you ever experienced any unfavorable reaction to dentistry
ls any part of your mouth sensitive to temperature or pressure
Have there been any injuries to your face, mouth, or teeth
Do your gums bleed when you brush
Do you have any oral habits, such as tongue thrust or thumb sucking
Are you a mouth breather
Do you clench or grind your teeth
Do you have tension headaches
Have you ever experienced chronic ringing in your ears
Are you pregnant
Has menstruation started
Have you seen a physician in the last 12 months
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05/10/2026Click to Sign
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05/10/2026Click to Sign
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