Orthodontic Questionnaire for Adults
Welcome to Palmetto Smiles! Please fill out all pages on this form to the best of your ability so that we may prepare for your first appointment.
Patient name
*
First Name
Last Name
Preferred name
Date of birth
*
-
Month
-
Day
Year
Date
Gender
*
Marital Status
Married
Single
Cell phone number
*
-
Area Code
Phone Number
Email address
*
example@example.com
Secondary contact
-
Area Code
Phone Number
Secondary contact name and relationship to patient
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any members of your immediate family who are patients of Palmetto Smiles?
*
Whom may we thank for referring you to our office?
*
Please enter full name of doctor, school, website or person.
What is your biggest concern with your bite/smile?
Place of employment
If full time student, school name
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Person Responsible For Financials
If you are the person responsible, you may mark self and skip the rest of the page.
Person responsible
*
Patient
Guardian
Spouse
Parent
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
SS#
Cell phone number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Person To Contact In Case Of Emergency
Outside immediate family
Name
*
First Name
Last Name
Phone number
*
-
Area Code
Phone Number
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Consent For Dental Consultation And Radiographs
A dental radiograph (x-ray) examination is one of the most important diagnostic tools your dentist uses to determine the presence of any dental disease and help you prevent dental diseases. Dental films enable the dentist to see inside bone and into the spaces between your teeth where even the smallest instrument cannot probe. Despite the preventative measures taken today by conscientious dentists and patients, problems can still develop in and around your teeth and supporting bone. You want the best possible care. Your dentist can give you the best care only with the help of a dental radiographic examination. With the aid of dental films, your dentist can often detect conditions that, if left untreated, would eventually affect the function and appearance of your teeth as well as your overall health.
I hereby give the Doctors of Palmetto Smiles my consent for dental consultation and radiographs. I have been informed of the reasons for radiographs. I also agree to accept financial responsibility for the treatment. I authorize release of any and all information: radiographs, photographs and models. I also understand they may be used for illustration and for documentation of my treatment.
*
Parent/guardian's signature
Clear
Date
*
-
Month
-
Day
Year
Date
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Medical History
Are you under a physicians care now?
*
No
Yes
If yes, who is your physician and what is the reason?
Have you ever been hospitalized or had a major operation?
*
No
Have you ever had a serious injury to your head or neck?
*
No
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?
*
No
Yes
If yes, please list
Are you on a special diet?
*
No
Are you allergic to any medications or substances?
*
No known allergies
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex rubber
If you are a woman, are you
Pregnant/trying to get pregnant
Nursing
Taking oral contraceptives
Do you now or have you ever had any of the following? If yes, please call prior to your appointment - premedication may be required.
*
Heart Disease/Surgery
Heart Murmur
Mitral Valve Prolapse
Rheumatic Fever
Artificial Heart Valve
Heart Pace Maker
Articifical Joint
Need premedication?
Ever taken fen-phen?
None
Do you now or have you ever had any of the following?
*
None of the following
COVID-19
Irregular Heart Beat
Angina/Chest Pain
Heart Attack/Failure
Congenital Heart Disorder
Scarlet Fever
Pulmonary Shunt
High Blood Pressure
Low Blood Pressure
Bacterial Endocarditis
Unexplained Fever
Anemia
Bruise Easily/Blood Disease
Excessive Bleeding
Sickle Cell Disease
Hemophilia (Bleeding Problem)
Leukemia
Recent Blood Transfusion
Swelling of Limbs
Lung Disease
Breathing Problem
Shortness of Breath
Frequent Cough
Hay Fever
Sinus Trouble
Asthma
Cancer
X-Ray Treatments (Radiation)
Chemotherapy
Bisphosphonates
Aredia I.V.
Zometa I.V.
Fosamax, Actonel, Boniva
Stomach/Intestinal Disease
Ulcers
Recent Weight Loss
Frequent Diarrhea
Diabetes
Excessive Thirst
Hypoglycemia
Liver Disease
Hepatitis A (Infectious)
Hepatitis B or C
Night Sweats
Yellow Jaundice
Kidney Problems
Renal Dialysis
Thyroid Disease
Parathyroid Disease
Arthritis/Gout
Rheumatism
Pain in Jaw Joints
Cortisone Medicine
Venereal Disease
AIDS
HIV Positive
Genital Herpes
Drug Addiction/Alcoholism
Tattoos/Body Piercing
Cold Sores
Fever Blisters
Herpes
Stroke
Convulsions
Epilepsy or Seizures
Fainting or Dizziness
Glaucoma
Tumors or Growths
Nervousness
Psychiatric Care
Alzheimer's Disease
Allergies (Medicines)
Allergies (Pollen/dust)
Hives or Rash
Have you ever had any other serious illness not listed above? If so, describe
Do you wish to speak to the dentist or orthodontist privately about any problem?
No
Yes
Date
*
-
Month
-
Day
Year
Date
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Dental History
Do you have a specific dental problems or pain? If yes, describe.
Who is your primary dentist?
*
Do you have dental examinations on a routine basis?
*
No
Yes
When was your last dental examination?
-
Month
-
Day
Year
Date
Were any x-rays taken?
*
No
Yes
Unsure
Do you think you have active decay or gum disease?
*
No
Yes
How often do you brush your teeth?
*
How often do you floss your teeth?
*
Do your gums ever bleed?
*
No
Yes
Do you ever have clicking, popping or discomfort in the jaw joint?
*
No
Yes
Do you brux or grind?
*
No
Yes
Do you have well water?
*
No
Yes
Do you smoke or chew tobacco?
*
No
Yes
Do you have any sores or growths in your mouth?
*
No
Yes
Do you have any sores or growths in your mouth?
*
No
Yes
Have your past experiences in a dental office always been positive?
*
No
Yes
Do you like your smile? If not, why?
To the best of my knowledge, all the preceding answers about medical and dental history are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.
*
Signature of Responsible Party
Clear
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Primary Dental Insurance Only
Please note we are not a participating or contracted provider with any insurance plan. We will verify your orthodontic benefit for you prior to your consultation.
Insured's name
First Name
Last Name
Insured's date of birth
-
Month
-
Day
Year
Date
Insured's SS#
Employer
Insurance company name
Group/Policy #
Claims phone number
-
Area Code
Phone Number
Claims address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Office Policies
Please click the link, review our office policies and sign below to indicate you have read and understand our policies.
Signature of Responsible Party
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Acknowledgement of Receipt of Notice of Privacy Practices
You may refuse to sign this acknowledgement. Please click the link, read and sign below to indicate you have read and understand the Notice of Privacy Practices.
I,
Name
, have received a copy of this office's Notice of Privacy Practices.
Signature of Responsible Party
Parent/Guardian's signature
Clear
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Authorization Compound
This authorization form permits Palmetto Smiles 139 Whiteford Way Lexington, SC 29072 to use or disclose protected health information listed in the description sections below to the Entity or Person listed in each section.
Patient name
*
First Name
Last Name
Patient date of birth
*
-
Month
-
Day
Year
Date
Voicemail/text/email authorization (We need at least one form of contact)
School/Employee Authorization
Other authorization (Grandparents, Aunt/Uncle, Friend, etc.)
General viewing and social media viewing
Photos - Office Placement
Comments
Contest Information
The purpose of this authorization is to meet the patient's request for information disclosures and uses. Expirations date or event: this authorization shall be enforced until revoked by the patient. Verification method or code: This practice will verify the identity of any entity requesting protected health information. Verification may include patient's date of birth:
-
Month
-
Day
Year
Patient's date of birth
Rights of the patient: I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. I understand that I have the right to revoke this authorization at any time by sending a written notification to the address listed at the top of this form. I understand that a revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to disclosure by the recipient and may no longer be protected by federal or state law.
Signature of Parent/Guardian or Personal Representative (as defined by HIPAA)
Clear
Date
-
Month
-
Day
Year
Date
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