dahlkeortho.com-Adult-NP-Medical

Name

First Name Middle Name Last Name

Title

Mr. Mrs. Ms. Miss Dr.

I Prefer To Be Called

Birth Date

Sex

Male Female

Social Security #

Marital Status

Single Married Separated Divorced Widowed

Physical Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Mailing Address (if different from above)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Cell Phone

Area Code Phone Number

Home Phone

Area Code Phone Number

Employer

Work phone

Area Code Phone Number

E-mail Address

example@example.com

Would you like to receive e-mails for announcements and appointment reminders from Dahlke Orthodontics? (No solicitation)

Yes No

Primary policy holder’s full name

First Name Last Name

Birth Date

Social Security #

Relationship to patient

Employer

City, State

Insurance Company

Group #

ID #

Insurance Co. Phone

Area Code Phone Number

Insurance Co. City, State

Does this policy have orthodontic benefits?

Yes No Don’t know

Secondary policy holder’s full name

First Name Last Name

Birth Date

Social Security #

Relationship to patient

Employer

City, State

Insurance Company

Group #

ID #

Insurance Co. Phone

Area Code Phone Number

Insurance Co. City, State

Does this policy have orthodontic benefits?

Yes No Don’t know

Spouse or closest relative’s name (s)

Relationship to you

Primary phone

What concerns you about your teeth?

Whom may we thank for referring you?

Has any previous orthodontic treatment or consultations occurred?

Yes No

If yes, where?

Have any other family members been treated in our office?

Yes No

If yes, Name

Patient’s Dentist

First Name Last Name

City, State

Last date seen

Reason

Next appointment

For the following questions, please mark yes, no, or don’t know/understand (dk/u).

MEDICAL HISTORY

Now or in the past, have you had:

	Yes	No	Dk/u
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anemia?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Vision, hearing, or speech problems?
Asthma, sinus problems, hayfever?
Cancer, tumor, radiation treatment or chemotherapy?
Have you ever taken intravenous bisphosphonates
such as Zometa (zolendromic acid), Aredia (pamidronate), Fosamax
(alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid
(tiludronate) or Didronel (etidronate) for bone disorders or cancer?

ALLERGIES

Have you had allergies or reactions to any of the following?

	Yes	No	Dk/u
Latex (gloves, balloons)
Local anesthetics (novocaine, lidocaine, xylocaine)
Metals (jewelry, clothing snaps)
Any Antibiotics (Penicillin)
Plant pollens (environmental)
Animals
Foods
Other substances

DENTAL HISTORY

Now or in the past, has the patient had:

	Yes	No	Dk/u
Erupting teeth very early or very late?
Extra (supernumerary) teeth?
Congenitally missing teeth?
Chipped or injured teeth?
Any missing or broken fillings?
Jaw fractures, cysts, infections?
Difficulty breathing through nose?
Frequent oral habits (sucking finger, thumb, pacifier)?
Clicking, locking in jaw joints?
Tooth grinding or clenching?

PATIENT HEALTH INFORMATION

Please list any medication, nutritional or herbal supplements, non-prescription medicines, including fluoride that you take.

	Medication	Taken for
1
2

Women:

	Yes	No
Are you pregnant?
Are you trying to become pregnant?

Any other medical conditions we should be aware of?

RELEASE AND WAIVER

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health history.

I authorize release of any information regarding my orthodontic treatment to my dental insurance company. As a condition of treatment by this office, I understand financial arrangements must be made in advance. I authorize and understand a complete examination to develop an orthodontic treatment plan sometimes includes x-rays, photographs, and study models. I have read the above conditions and agree to their content.

Patient Signature

Clear

Date

PATIENT INFORMATION

DENTAL INSURANCE

EMERGENCY CONTACT

GENERAL INFORMATION

DENTIST