ADULT PATIENT INFORMATION FORM
TELL US ABOUT YOU:
Today's Date:
Name:
Last
First
MI
I prefer to be called:
Male
Female
What is your chief concern or reason for seeking Orthodontic treatment?
Birth date:
Social Security #:
Age
Marital status:
Single
Married
Separated
Divorced
Widowed
Domestic Partnership
Home phone:
(
)
Home Address
City
State
Zip
Best # For Appointment Confirmation:
(
)
E-mail Address:
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 (if applicable)
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
WHOM MAY WE THANK FOR REFERRING YOU?
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
Please list all medications that you are currently taking:
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
Please fill out the insurance section only if you have ORTHODONTIC insurance.
PRIMARY ORTHODONTIC INSURANCE:
Insurance Co. Name:
Subscriber ID (Plan, Local or Policy #):
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:
Please fill out the insurance section only if you have ORTHODONTIC insurance.
SECONDARY ORTHODONTIC INSURANCE:
Insurance Co. Name:
Subscriber ID (Plan, Local or Policy #):
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:
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)