Adult Patient Information
Patient Name
*
First Name
Last Name
Nickname/Preferred Name
Gender
Male
Female
Prefer not to state
Social Security Number
BirthDate
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Phone Type
*
Home
Cell
If cell, please list provider
Secondary Phone Number
Phone Type
Home
Cell
If cell, please list provider
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
Primary Insurance Company
Phone Number
Subscriber Name
Policy Holder's SSN
Policy Holder's Date of Birth
-
Month
-
Day
Year
Date
Dental History
General Dentist
Date of Last Visit
-
Month
-
Day
Year
Date
How did you hear about our practice?
*
Ad
Internet
Family/Friend
Dentist
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 use any tobacco?
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
*
(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
Back Problems
Blood Disease
Cancer
Chemotherapy
Circulatory Problems
Cough, Persistent
Coughing Blood
Diabetes
Epilepsy
Fainting
Headaches
Heart Murmur
Heart Problems
Hepatitis
High Blood Pressure
HIV/AIDS
Jaw Pain
Kidney Disease
Liver Disease
Mitral Valve Prolapse
Pacemaker
Radiation Treatment
Respiratory Disease
Shortness of Breath
Stroke
Tonsilitis
Tuberculosis
None
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.
Submitted by
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
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