Adult Patient Information
Patient Name
*
First Name
Last Name
Gender
*
Male
Female
Social Security Number
*
BirthDate
*
-
Month
-
Day
Year
Date
Age
*
Signature
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
At your home address, do you:
*
Rent
Own
Primary Phone Number
*
How long have you lived at your current address?
*
Please Select
Less than 1 year
1-2 years
2.1-2.9 years
3-3.9 years
4-5.9 years
6-9.9 years
10+ years
Phone Type
*
Home
Cell
Ok to leave message?
*
Yes
No
Email
*
example@example.com
Employer's Name
*
Occupation
*
How long have your worked at your current job?
*
Spouse/Partner
Spouse/Partner's Name
Marital Status
Single
Married
Divorced
Widowed
Significant Other
Social Security Number
Birthdate
-
Month
-
Day
Year
Date
Address (if different than patient)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone
Phone Type
Home
Cell
Secondary Phone
Phone Type
Home
Cell
Emergency Contact Information
Emergency Contact's Name
Phone Number
Relation to Patient
Primary Dental Insurance Information
Do you have Dental Insurance?
*
Yes
No
Primary Insurance Company
Phone Number
Subscriber Name
Policy Holder's SSN
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Picture Upload for Front & Back of Insurance Card
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Dental History
General Dentist
Date of Last Visit
-
Month
-
Day
Year
Date
How did you hear about our practice?
Ad
Internet
Family/Friend
Physician
Other
Name of person referring (if applicable)
What are the main concerns you would like orthodontics to correct?
Have you visited an orthodontist before?
Yes
No
If yes, when
-
Month
-
Day
Year
Date
Reason for visit
Have your tonsils or adenoids been removed?
Yes
No
Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Yes
No
Do you have any missing or extra permanent teeth?
Yes
No
Have you ever had an injury to (select all that apply)
Teeth
Mouth
Chin
Do you have speech problems?
Yes
No
If so, explain
Do your gums bleed?
Yes
No
Do you smoke?
Yes
No
Do you like your smile?
Yes
No
Do you currently or have you ever had any of the following habits (check all that apply)
Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem
Medical History
Are you currently being treated by a physician?
Yes
No
Name of Primary Care Physician
Reason for Last Visit:
Do you have any allergies/sensitivities to medications or latex?
Yes
No
If yes, please list
Are you currently taking any prescription or over-the-counter medications?
Yes
No
If yes, please list with the dosage
Have you had any serious illnesses or operations? If yes, describe
Have you ever had a blood transfusion?
Yes
No
If yes, give approximate dates
(Women) Are you pregnant?
Yes
No
Check if you have ever had any of the following:
Anemia
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Autism/Asperger's Syndrome
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chemotherapy
Circulatory Problems
Cortisone Treatments
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Rheumatic Fever
Scarlet Fever
Shortness of Breath
Skin Rash
Stroke
Swelling of Feet or Ankles
Thyroid Problems
Tobacco Habit
Tonsilitis
Tuberculosis
Ulcer
Venereal Disease (STD)
Authorization
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 of confidence and it is my responsibility to inform the office of any changes in my medical status.I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.I understand that where appropriate, credit bureau reports may be obtained.
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Date
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