We look forward to seeing you:
at
am / pm
We would appreciate you arriving 10 minutes before
the appt time with this form completed.
Jeffery C. Summers, DMD
Today’s Date:
ADULT FORM
Please take this time to tell us about yourself.
Name
First
Middle
Last
Mr.
Mrs.
Ms.
Miss
Dr.
I prefer to be called
Male
Female
Birth Date
Age:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-mail Address:
Hobbies:
Single
Married
Divorced
Separated
Widowed
Children (Please list names and ages.)
Have any other family been seen in our office? Names:
EMPLOYER INFORMATION
Employer:
Occupation:
Work Address:
City:
State:
Zip:
Work
How long there?
SPOUSE INFORMATION
His / Her Name:
Birth Date
Age:
Employer
Occupation:
Work Phone
Ext
How did you hear about our office?
Who may we thank for referring you to our office?
INSURANCE
Primary Dental Insurance
Orthodontic Coverage:
Yes
No
Employer:
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone:
Insured Name:
Relation to Patient
Birth Date
Member ID:
SS#:
Fee Expectations
If treatment is recommended, what is your ideal DOWN payment?
$500-$749
$750-$999
$1000+
Pay in full & receive a courtesy discount
If treatment is recommended, what is your ideal MONTHLY payment?
$100-$199
$200-$299
$300-$399
I have an HSA or FSA to use
If treatment is recommended, what is your desired time frame to begin this exciting journey?
ASAP/Today
Shopping for options
I would like to get scheduled
Unsure
PERSON RESPONSIBLE FOR ACCOUNT
Name:
Relationship
Billing Address:
City:
State:
Zip:
Home:
Cell:
Emergency Contact:
Relation:
Phone:
GENERAL DENTIST
Name:
Last Dental Exam:
My dentist referred me to:
You
Another Orthodontist
None
Continued on other side...
4207 East North St. Greenville, SC 29615
phone (864) 244-7545
fax (864) 244-7767
www.summersortho.com
MEDICAL HISTORY
A complete history is vital for a proper orthodontic evaluation.
Physician:
Phone No:
Date of last visit:
Are you taking any prescription medication:
Yes
No
If yes, please list which one(s):
For Women:
Are you pregnant?
Yes
No
Have you ever had any of the following diseases or medical problems? (Please circle all that apply.)
Abnormal Bleeding
Hepatitis
AIDS or HIV positive
Immune System
Artificial Bones / Joints
Jaundice or Liver Problems
Asthma
Kidney Problems
Birth Defects
Mental Health / Behavioral
Blood Pressure-High or Low
Mitral Valve Prolapse
Bone Disorders
Nervous Problems
Cancer or Tumors
Neurological Problems
Chest Pain
Pneumonia
Congenital Heart Defect
Polio, Mono or Tuberculosis
Convulsions
Prosthetics
Diabetes
Radiation / Chemotherapy
Ear, Nose or Throat
Rheumatic or Scarlet Fever
Endocrine or Thyroid
Rheumatoid / Arthritic
Epilepsy
Sickle Cell Disease / Traits
Excessive Weight Loss/Gain
Skin Disorders
Fainting Spells or Seizures
Speech Difficulties
Handicap / Disabilities
Stomach Ulcers/Hyperacidity
Hay Fever or Sinus Trouble
Swelling Ankles
Hearing Impairment
Tuberculosis
Heart Trouble / Murmur
Vision Difficulties
Any Hospital Stays / Operations?
Are there any medical conditions we have not discussed that you feel
we should be aware of?
MEDICAL ALERT INFORMATION
Do you normally require antibiotic pre-medication prior to dental
procedures?
Yes
No
Are you allergic to any of the following?
Latex
Yes
No
Plastic
Yes
No
Nickel
Yes
No
Aspirin
Yes
No
Erythromycin
Yes
No
Codeine
Yes
No
List any other allergies:
Are you currently taking or have you ever taken intravenous bisphosphonates for serious bone disorder/cancers: such as Zometa (zolendronic acid), Aredia
(pamidronate), Didronel (etidronate)?
Yes
No
Are you currently taking or have you ever taken any oral bisphosphonates for osteoporosis, osteopenia or other uses: such as Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Skelid (tiludronate), Didronel
(etidonate)?
Yes
No
Being treated by another health care professional?
Yes
No
For:
Date of most recent physical exam?
DENTAL HISTORY
Have you ever been evaluated by an Orthodontist?
Yes
No
If so, by whom?
Have you ever had orthodontic treatment?
Yes
No
If so, by whom?
Were you happy with the results?
Yes
No
Have other members of your family had orthodontic treatment?
Yes
No
Were you happy with the results?
Yes
No
By whom (if other than Dr. Summers)?
Chief complaint or reason for your visit today?
Appearance
If you could change one thing with the appearance of your teeth or
your bite, what would it be?
Are you happy with your smile?
Yes
No
Do you like the shape of your teeth?
Yes
No
Are you happy with your profile and jaw line?
Yes
No
Are you happy with the amount of gum tissue that you show when
smiling?
Yes
No
Function
Do you experience pain, clicking or discomfort in or near your ears?
Yes
No
Do you have pain or tenderness in your jaw joints (TMJ / TMD)?
Yes
No
Have there been any injuries to the face, mouth, teeth or chin?
Yes
No
Have you been informed of missing or extra permanent teeth?
Yes
No
Are you aware of any gum problems?
Yes
No
Have your tonsils or adenoids been removed?
Yes
No
Habits
Do you or did you have any of the follow habits? (Please circle)
Clenching / Grinding Teeth
Lip Sucking / Biting
Mouth Breather
Nail Biting
Thumb / Finger Sucker
(Until:
age)
I hereby certify that I have reviewed the above medical and dental history and agree that it is, to the best of my knowledge, accurate at this time. I am also aware that communication with dentist/specialist may be necessary for treatment. If there are any future changes in this information I will inform the practice of these changes.
Patient’s Signature
Date
Doctor’s Signature
Date