New Patient Form | David Lee Smile

Are you currently under the care of a physician:

Y N

Please Explain:

Are you taking any prescription drugs:

Y N

Please list each one:

For Women: Are you using a prescribed method of birth control?

Y N

Are you pregnant:

Y N

Week #:

Are you nursing:

Y N

Have you ever had any of the following diseases or medical problems?

Check to fill all answers “No”. You will still be able to select “yes” for individual questions.

Abnormal Bleeding

Y N

Anemia

Y N

Artificial Bones/Joints

Y N

Asthma/Arthritis

Y N

Blood Transfusion

Y N

Cancer/Chemotherapy

Y N

Congenital Heart Defect

Y N

Diabetes

Y N

Difficulty Breathing

Y N

Drug/Alcohol Abuse

Y N

Emphysema

Y N

Epilepsy/Seizures/Fainting

Y N

Fever Blisters/Herpes

Y N

Glaucoma

Y N

Heart Attack/Stroke

Y N

Heart Murmur

Y N

Heart Surgery/Pacemaker

Y N

Hemophilia

Y N

Hepatitis

Y N

Hi/Lo Blood Pressure

Y N

HIV+/Aids

Y N

Hospitalization

Y N

Kidney Problems

Y N

Mitral Valve Prolapse

Y N

Psychiatric Problems

Y N

Radiation Treatment

Y N

Rheumatic Fever

Y N

Sev/Freq.Headaches

Y N

Shingles

Y N

Sickle Cell Trait/Disease

Y N

Sinus Problems

Y N

Tuberculosis (TB)

Y N

Ulcers/Colitis

Y N

Venereal Disease

Y N

Please list any serious medical condition(s) that you have ever had

Are you allergic to any of the following:

Check to fill all answers “No”. You will still be able to select “yes” for individual questions.

Aspirin

Y N

Dental Anesthetics

Y N

Penicillin

Y N

Metals/Plastics

Y N

Erythromycin

Y N

Tetracycline

Y N

Codeine

Y N

Latex

Y N

Other

Please List any other drugs/materials that you are allergic to:

What are the main concerns that you want orthodontics to accomplish?

Ever been evaluated for ortho?

Y N

Problem with dental work in the past?

Y N

Experienced pain in your jaw joint?

Y N

Your current dental health is:

Good Fair Poor

Do you like your smile?

Y N

Gums Bleed?

Y N

Do you generally breath through your mouth?

Y N

Do you have speech problems?

Do you have any missing or extra teeth?

Y N

Have you ever taken Fosamax/Bisphosphate?

Y N

Have you ever taken Phen-Fen?

Y N

Do you smoke tobacco?

Y N

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature

Date

If Lee Orthodontics accepts my dental insurance, I understand that I am responsible for any co-payments/deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.

Signature

Date

Lee Orthodontics is HIPAA Compliant and is committed to meeting or exceeding the standard of infection control mandated by OSHA, the CDC, and ADA.

About You (Patient)

Additional Information

Orthodontic Insurance

Primary

Secondary

Medical History

Dental History