Adult Patient Information

A B C

ADULT PATIENT INFORMATION

Date______

Patient’s name______

LastFirstMiddle

Residence______

StreetCityZip

Mailing Address______

StreetCityZip

How long at this address?______Home phone______Work phone______

Previous Address (If less than 3 years)______

Cell Phone______Birthdate______Social Security #______

Email Address______Marital Status: Single__ Married__ Widowed__ Separated__ Divorced___

Employer______Occupation______No. years employed_____

Spouse’s Name______Relationship to Patient______

Employer______Occupation______No. years employed_____

Social Security #______Birthdate______Work Phone______

Whom may we thank for referring you to our office?______

DENTAL INSURANCE INFORMATION

Insured’s Name______Insured’s Social Security #______

Insurance Company______Group No.______Local No.______

Insurance Co. Address______Phone No.______

Do you have dual coverage? Yes_____ No_____ If yes:

Insured’s Name______Insured’s Social Security #______

Insurance Company______Group No.______Local No.______

Insurance Co. Address______Phone No.______

EMERGENCY INFORMATION

Name of nearest relative not living with you______

Complete address______

StreetCityZip

Phone______

I understand that, where appropriate, credit bureau reports may be obtained.

Signature ______

Updates (date & initial)______

MEDICAL HISTORY

Physician______Date of Last Visit______

Address______Phone______

Please circle Yes or No (If Yes, please fill in details)

YesNoAre you taking any medication? ______

YesNoAre you allergic to any medication? ______

YesNoDo you have a history of a major illness?______

YesNoHave you had any operations?______

YesNoHave you ever been involved in a serious accident?______

YesNoHave you ever smoked or chewed tobacco?______

YesNoHave seen a physician in the last 12 months? Why?______

Female Patients only:

YesNoAre you pregnant?______

YesNoHas menstruation started?______

Circle any of the medical conditions below that you have had or currently have.

Abnormal bleeding/HemophiliaDiabetesHepatitis/Liver problemsPneumonia

AnemiaDizzinessHerpesProlonged Bleeding

ArthritisEpilepsyHigh Blood PressureRadiation/Chemotherapy

Asthma or HayfeverGastrointestinal DisordersHIV / AidsRheumatic Fever

Bone DisordersHeart ProblemsKidney problemsTuberculosis

Congenital Heart DefectHeart MurmurNervous DisordersTumor or Cancer

Are there any medical conditions we have not discussed that you feel we should be aware of?______

______

DENTAL HISTORY

General Dentist______Date of last visit______

What concerns you most about your teeth?______

YesNoAre you presently in any dental pain?______

YesNoHave you ever experienced any unfavorable reaction to dentistry?______

YesNoHave your wisdom teeth been removed?______

YesNoHave you ever lost or chipped any teeth?______

YesNoHave there been any injuries to face, mouth, or teeth?______

YesNoIs any part of your mouth sensitive to temperature? Where?______

YesNoIs any part of your mouth sensitive to pressure? Where?______

YesNoDo your gums bleed when you brush?______

YesNoDo you have any type of thumb or tongue habit?______

YesNoAre you a mouth breather?______

YesNoHave you ever seen an orthodontist? If yes, who and when?______

YesNoWhat is your attitude toward receiving orthodontic treatment?______

YesNoHas anyone in your family received orthodontic treatment?______How did they feel about the result?

YesNoDo your teeth or jaws ever feel uncomfortable when you awake in the morning?______

YesNoAre you aware of your jaw clicking or popping?______

YesNoAre you aware of clenching your teeth during the day?______

YesNoHave you ever been told that you grind your teeth?______

YesNoDo you have “tension” headaches?______

YesNoHave you ever experienced chronic ringing in your ears?______

YesNoAre you aware that some appointments will be during work hours?______

BENEFITS

Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. ______to perform a complete orthodontic evaluation.

Signature:______Date:______