Adult Orthodontic Questionnaire

Adult Orthodontic Questionnaire

In order for us to properly diagnose and treat our patients, we must have accurate background and health information on which to base our decisions. Please provide the information requested below:
Patient's Name*

First NameLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Age:*
Marital Status:*
Social Security Number:*
Driver's License Number:*
Email Address:*
example@example.com
Home Phone:*
Please enter a valid phone number.
Work Phone:*
Please enter a valid phone number.
Cell Phone:*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Dentist:*
Patient's Physician:*
Referred By:
Patient's Occupation:*
Employer*
Name of Dental Insurance Company:*
Dental Insurance Company Phone Number:
Please enter a valid phone number.
Insurance ID:*
Insurance Group Number:*
Insurance Address PO Box:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Account:*
Is the Patient Covered By Insurance for Orthodontic Treatment?*

YesNo
Is the Patient Covered By Insurance for TMJ Treatment?*

YesNo
Name of Medical Insurance Company:*
Medical Insurance Company Phone Number:*
Please enter a valid phone number.
Medical Insurance ID:*
Medical Insurance Group Number:*
Medical Insurance Address PO Box:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSTRUCTIONS: the first part of your health questionnaire is designed to help us focus upon your specific concerns. The second part of the questionnaire will allow you to provide any explanations necessary to enhance our overall understanding. Please complete all appropriate answers as accurately as possible. Your confidentiality will be respected.
What are the parent’s or patient’s main concerns regarding the jaws and teeth?*

CrowdingOver-bite"Buck" teethReceded jawProminent jawGummy smileSpacesGum disease/recessionMissing teethJaw dysfunctionMouth too smallClicking jaw jointIrregularly shaped teethProtrusion of teethRinging/Stuffiness of earsHeadaches/facial painNeck painJaw painIrregular facial proportionsNone of the aboveOther
Other family members with similar orthodontic condition*

MotherFatherBrotherSisterOther
Patient's marital status*

MarriedDivorcedSeparatedSingleWidowed
Medical/Dental History
Present Physical Health*

ExcellentGoodFairPoor
Present Emotional Health*

ExcellentGoodFairPoor
Has the patient ever had any of the following conditions?*

AIDSAllergiesArteriosclerosisAsthmaAutoimmune disorderBlood diseaseHigh Blood pressureLow blood pressureBone disordersCancerDiabetesDizzinessEpilepsyEndocrine ProblemsEmotional problemHsFemale problemsHepatitisHeart diseaseHearing disorderKidney DiseaseRheumatic feverRinging of earsSleep disturbanceReceived trauma (teeth, face, jaws, or head)Other
Medications
Current medications taken by patient*

Heart pHills (digitalis, etc.)AntibioticsDiet Pills (diuretics)Pain pills (demerol, codiene, etc.)VitaminsBirth control pillsSleeping pillsMuscle relaxantsInsulinNot taking any medicationOther
Alergies to Medication/Food
The patient demonstrates an allergic response to:*

AntibioticsPain pills (codeine, etc.)Dairy ProductsWheat, cerealsDyes in foodNo food/medication allergiesOther
The following are of interest to the orthodontist:
Does the patient drink more than 1 glass of milk per day?*

YesNo
Does the patient have frequent colds?*

YesNo
Does the patient have frequent sore throats or tonsillitis?*

YesNo
Does the patient have difficulty chewing?*

YesNo
Does the patient have pain in the jaw joint?*

YesNo
The following habits are of interest to the orthodontist:
Thumb sucking*

NeverPreviouslyPresently
Finger sucking*

NeverPreviouslyPresently
Lip biting or sucking?*

YesNo
Grinding of teeth?*

YesNo
Tongue thrusting?*

YesNo
Smoking?*

YesNo
Please list any other habits that could potentially be of interest to the orthodontist
Patient's attitude toward teeth, face, and orthodontic treatment
Dental checkups*

Twice a yearOnce a yearOnly if urgentNever
Are you aware of any orthodontic problems?*

YesNo
Previous orthodontic consultation or treatment*

YesNo
Any unusual dental experiences?*

YesNo
Are there any medical, dental, or surgical problems not covered above?*

YesNo
If so, please list them here
Why are you seeking this consultation?*

To correct overbiteTo eliminate crowdingto correct jaw disfunction problemTo eliminate facial painTo close spacesTo improve facial proportionsTo improve general appearanceOther
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty: