ADULT PATIENT INFORMATION

ADULT PATIENT INFORMATION FORM

TELL US ABOUT YOU:

Today's Date:

Name:

Last

First

I prefer to be called:

Male

Female

What is your chief concern or reason for seeking Orthodontic treatment?

Birth date:

Drivers License #

Social Security #:

Age

Marital status:

Home phone:

(

)

Home Address

City

State

Zip

Cell phone:

(

)

Pager phone:

(

)

E-mail Address:

Name of employer:

Work phone:

(

)

Work Address

City

State

Zip

Dentist's Name:

Phone #:

(

)

Date of last visit:

Physician's Name:

Phone #:

(

)

Date of last visit:

Other family members seen by us:

Name

Relation to you

SPOUSE'S INFORMATION:

Name:

Work Phone #:

(

)

Home Phone #:

(

)

Cell Phone #:

(

)

Address(if different from patient):

E-mail Address:

Employer:

EMERGENCY CONTACT INFORMATION:

Name:

Relation to you:

Work Phone #:

(

)

Home Phone #:

(

)

Cell Phone #:

(

)

Home Address:

Name of Employer:

Work Address:

City

State

Zip

PERSON RESPONSIBLE ACCOUNT:

(check one):

Self

Spouse

Other

Fill in section below if you checked Spouse or Other

Name:

Employer:

DL#:

Work Phone #:

(

)

Home Phone #:

(

)

Social Security #:

Billing Address:

City

State

Zip

Previous Address:

City

State

Zip

WHOME MAY WE THANK FOR REFERRING YOU?

Please fill out the insurance section only if you have ORTHODONTIC insurance.

PRIMARY ORTHODONTIC INSURANCE:

Group # (Plan, Local or Policy #):

Insurance Co. Name:

Insurance Co. Address:

Insurance Co. Phone #:

Policy Owner's Name:

Relation to Patient:

Policy Owner's Social Security #:

Policy Owner's Employer:

Date of Birth:

Employer's Address:

Our office is committed to meeting or exceeding the standards of infection control
mandated by OSHA, the CDC and the ADA.

We reserve the right to verify the credit status prior to extending credit for treatment.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.

Date

Signature (Sign with mouse)

	CIRCLE ONE:			CIRCLE ONE
Do you currently feel healthy?	YES	NO	Do you still have your wisdom teeth?	YES	NO
Have you ever been evaluated or had orthodontic treatment before?	YES	NO	Have there been any injuries to your face, mouth, teeth or chin?	YES	NO
Have you been informed of any missing or extra permanent teeth?	YES	NO	Do you need to be premedicated before dental work?	YES	NO
Have you experienced problems with previous dental work?	YES	NO	Have adenoids or tonsils been removed?	YES	NO
Have you ever had any pain / tenderness in your jaw joint (TMJ/TMD)?	YES	NO	Do you brush your teeth daily?	YES	NO
Has your jaw ever clicked, popped or locked?	YES	NO	Do you floss your teeth daily?	YES	NO
Have you noticed your teeth shifting or a change in your bite?	YES	NO	Do your gums bleed?	YES	NO
Do you have frequent headaches?	YES	NO	Are you taking fluoride supplements?	YES	NO
Do you play any musical instruments?	YES	NO	Females: Do you take birth control pills?	YES	NO
If so, what?			Are you pregnant?	YES	NO

Are you Allergic to any of the following?	Do you now have or have you had any of the following habits?	Do you now have or have you had any of the following?
Y N Aspirin Y N Any Metal(e.g.Nickel) Y N Plastic Y N Codeine Y N Dental Anesthetics Y N Erythromycin Y N Latex Y N Penicillin Y N Tetracycline Y N Sulfa drugs Y N Other Please list any other Allergies that you have:	Y N Tongue Thrust Y N Clenching / Grinding Teeth Y N Lip Sucking / Biting Y N Speech Problems Y N Mouth Breather Y N Nail Biting Please list any other Habits that you have:	Y N Allergies Y N Abnormal/Bleeding Disorders Y N Any Hospital Stays Y N Asthma Y N Cancer Y N Canker Sores Y N Cardiovascular disease Y N Chicken Pox Y N Cold Sores / Fever Blisters Y N Convulsions / Epilepsy Y N Damaged / artificial heart valves Y N Diabetes Y N Handicaps / Disabilities Y N Hearing Impairment	Y N Heart Murmur Y N Hemophilia Y N Hepatitis/Liver Problems Y N High Blood Pressure Y N Hives Y N HIV+ / AIDS Y N Kidney Problems Y N Measles Y N Mononucleosis Y N Psychological Counseling Y N Rheumatic / Scarlet Fever Y N Skin Rash Y N Tuberculosis (TB) Y N Tumors/growths Y N Ulcers