ADULT NEW PATIENT FORM
Please fill in the form below
PATIENT INFORMATION
Patient's Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Student or Occupation
*
Marital Status
Single
Married
Separated
Divorced
Widowed
Spouse's Name (if married)
General Dentist
*
Approximate Date of Last Visit
*
Whom May We Thank for Referring You
*
Who is financially responsible for the patient?
I am 18+ years old and responsible for myself.
Spouse
Parent
Other
RESPONSIBLE PARTY (Other than yourself)
*FILL THIS PORTION OUT ONLY IF SOMEONE ELSE IS LEGALLY & FINANCIALLY RESPONSIBLE FOR YOU AND HAS AGREED TO SIGN ALL FINANCIAL AND CONSENT FORMS*
Full Name
First Name
Middle Name
Last Name
Relationship to You
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Do you have dental insurance?
*
Yes
No
PRIMARY DENTAL INSURANCE
Subscriber's Name
First Name
Middle Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to You
Subscriber's Employer
Insurance Company
Example: Delta Dental of California
Insurance Company's Phone Number
-
Area Code
Phone Number
Subscriber's ID# or Social Security #
Group #
Do You Have A Secondary Dental Insurance?
Yes
No
SECONDARY DENTAL INSURANCE
Subscriber's Name
First Name
Middle Name
Last Name
Subscriber's Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to You
Subscriber's Employer
Insurance Company
Example: Delta Dental of California
Insurance Company's Phone Number
-
Area Code
Phone Number
Subscriber's ID# or Social Security #
Group #
EMERGENCY CONTACT
Nearest Relative Not Living With You
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
MEDICAL HISTORY
Name of Primary Care Physician
First Name
Last Name
Approximate Date of Last Visit
-
Month
-
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have You Ever Had Any of the Following
Heart Attack / Stroke
YES
NO
High Blood Pressure
YES
NO
Low Blood Pressure
YES
NO
Diabetes
YES
NO
Rheumatic Fever
YES
NO
Hemophilia / Abnormal Bleeding
YES
NO
Cancer / Chemotherapy / Radiation
YES
NO
Kidney Problems
YES
NO
Asthma
YES
NO
Adenoids / Tonsils Removed
YES
NO
Tuberculosis
YES
NO
VD (Syphilis, Gonorrhea)
YES
NO
HIV / AIDS
YES
NO
Major Operations
YES
NO
Psychiatric / Learning Problems
YES
NO
ADHD
YES
NO
Epilepsy / Seizures / Fainting Spells
YES
NO
Heart Murmur / Heart Disease
YES
NO
Is Pre-Medication Required
YES
NO
Heart Surgery / Pacemaker
YES
NO
Mitral Valve Prolapse
YES
NO
Artificial Bones / Joints
YES
NO
Sinus / Breathing Problems
YES
NO
Hepatitis
YES
NO
Congenital Heart Disease
YES
NO
Pain / Pressure / Tightness in Chest
YES
NO
List Any Other Medical Conditions
PLEASE CHECK ALL THAT APPLY
Pregnant
YES
NO
On a Prescribed Diet
YES
NO
Using Thyroid Drugs
YES
NO
Using Anxiety Medications
YES
NO
Have you taken Bisphosphonate Drugs
YES
NO
Premature Birth
YES
NO
Using Dilatin or Equivalent
YES
NO
Using Hormones (Including Birth Control)
YES
NO
Genetic Disorder
YES
NO
List Any Other Medical Conditions
Are You Taking Medications For:
Diabetes
YES
NO
Nerves (Tranquilizers / Relaxants)
YES
NO
Sleeping
YES
NO
Heart / Blood Pressure
YES
NO
Blood (Liver / Iron Pills)
YES
NO
Stomach Trouble
YES
NO
Headaches
YES
NO
Allergies
YES
NO
Are You Aware of Any Allergies
Aspirin/Codeine
YES
NO
Sulfa Drugs
YES
NO
Dental Anesthetic (Ex. Novacain)
YES
NO
Metal / Nickel Allergies
YES
NO
Penicillin / Tetracycline / Erythromycin
YES
NO
Other Antibiotics
YES
NO
Latex/Rubber Gloves
YES
NO
Other
Back
Next
DENTAL HISTORY
What is the main reason for seeking Orthodontic treatment?
Have you had previous Orthodontic treatment? If so, by whom?
Do you have missing permanent teeth? If so, list:
Do you pre-medicate before your dental appointment?
YES
NO
Do your gums bleed when you are brushing?
YES
NO
Have you ever been told you have 'gum disease' or Periodontitis?
YES
NO
Have you ever had professional instructions on dental home care?
YES
NO
Is any part of your mouth sensitive to temperature or pressure?
YES
NO
Does food catch between your teeth?
YES
NO
Do you have any soreness around your eyes or ears?
YES
NO
Do you have any unpleasant odor, or taste in your mouth?
YES
NO
Are you dissatisfied with the appearance of your teeth?
YES
NO
Are you currently experiencing any pain?
YES
NO
Have other family members had treatment in our office?
YES
NO
Do You Have Any of the Following?
Ringing in the Ears
YES
NO
Neck Pain
YES
NO
Back Pain
YES
NO
Headaches
YES
NO
Dizziness
YES
NO
Pain in Teeth
YES
NO
Face Pain
YES
NO
Jaw Pain
YES
NO
Grinding of Teeth
YES
NO
Popping / Clicking of Jaw Joint
YES
NO
Have You Ever Experienced the Following?
Been in an Accident
YES
NO
Explain:
A Blow to the Jaw
YES
NO
Explain:
An Injury to the Mouth / Teeth / Chin
YES
NO
Explain:
Your Jaw Joint Lock or Felt Like it was Sticking
YES
NO
Explain:
Would you say your dental health is
POOR
FAIR
GOOD
By signing below, I certify that the information I have provided today is complete and accurate. I also understand that it is my responsibility to inform the office of any changes regarding my child's mental health. I authorize Bailey Orthodontics Staff to perform necessary dental services that my child may need during diagnosis and treatment.
*
Sign and Date
I hereby authorize my insurance benefits to be paid directly to Bailey Orthodontics Office and I authorize Bailey Orthodontics to release any information to process insurance claims.
*
Sign and Date
Date
*
/
Month
/
Day
Year
Date
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