dahlkeortho.com-Adult-NP-Medical

PATIENT INFORMATION
Name

First NameMiddle NameLast Name
Title

Mr.Mrs.Ms.MissDr.
I Prefer To Be Called
Birth Date

MonthDayYear
Sex

MaleFemale
Social Security #
Marital Status

SingleMarriedSeparatedDivorcedWidowed
Physical Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
Employer
Work phone

Area CodePhone Number
E-mail Address
example@example.com
Would you like to receive e-mails for announcements and appointment reminders from Dahlke Orthodontics? (No solicitation)

YesNo
DENTAL INSURANCE
Primary policy holder’s full name

First NameLast Name
Birth Date

MonthDayYear
Social Security #
Relationship to patient
Employer
City, State
Insurance Company
Group #
ID #
Insurance Co. Phone

Area CodePhone Number
Insurance Co. City, State
Does this policy have orthodontic benefits?

YesNoDon’t know
Secondary policy holder’s full name

First NameLast Name
Birth Date

MonthDayYear
Social Security #
Relationship to patient
Employer
City, State
Insurance Company
Group #
ID #
Insurance Co. Phone

Area CodePhone Number
Insurance Co. City, State
Does this policy have orthodontic benefits?

YesNoDon’t know
EMERGENCY CONTACT
Spouse or closest relative’s name (s)
Relationship to you
Primary phone
GENERAL INFORMATION
What concerns you about your teeth?
Whom may we thank for referring you?
Has any previous orthodontic treatment or consultations occurred?

YesNo
If yes, where?
Have any other family members been treated in our office?

YesNo
If yes, Name
DENTIST
Patient’s Dentist

First NameLast Name
City, State
Last date seen

MonthDayYear
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

MonthDayYear
Should be Empty:

PATIENT INFORMATION

DENTAL INSURANCE

EMERGENCY CONTACT

GENERAL INFORMATION

DENTIST