Adult Patient Form Patient Information Date Date of birth Age Patient's Last Name Patient's First Name Middle Name Preferred Name Patient's Address City Zip Home Phone Cell Phone Business Phone Email Social Security Number Employer Ocupation Business Address Business City Business Zip Marital Status Status Single Married Divorced Remarried Widowed Name of Spouse Spouse's Ocupation Spouse's Employer Reason for Visit? YesNoHas the patient received previous orthodontic consultation? Whom might we thank for your referral? YesNoDo you have any other family members in our practice? Dental History Dentist Phone Dentist's Address City Zip Other Dentist Specialty Other Dentist's Address City Zip Phone Date of last dental visit Date of last dental visit Medical History Family Physician Specialty Physician's Address City Zip Phone Additional Physician Specialty Additional Physician's Address City Zip Phone Date of last complete medical examination Insurance Information Primary Insurance Primary Insurance Company Insurance Customer Service Number Dental Claims Mailing Address City Zip Group Number Member ID Number Policy Holder's Name Policy Holder's SSN Policy Holder's Birth Date Policy Holder's Employer Orthodontic Lifetime Maximum Secondary Insurance Secondary Insurance Company Secondary Insurance Customer Service Number Dental Claims Mailing Address City Zip Group Number Member ID Number Policy Holder's Name Policy Holder's SSN Policy Holder's Birth Date Policy Holder's Employer Orthodontic Lifetime Maximum Medical History(continued) YesNoAre you having dental pain or discomfort? YesNoAre you currently under physicians care? YesNoAre taking any medications? YesNoAre allergic to any medications, food, latex? YesNoDo you take any medications prior to dental treatment? YesNoHave you ever had any excessive bleeding requiring special treatment? YesNoHave you ever had any trauma YesNoHas anyone in your family had orthodontic treatment that has caused root resorption? YesNoWhen you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or becuase you are very tired? YesNoDo your ankles swell during the day? YesNoDo you have any disease, condition, or problem not listed? Women: YesNoAre you pregnant now? YesNoDo you anticipate becoming pregnant? YesNoDo you breath through your mouth? YesNoDo you snore when you are asleep? YesNoDo you sleep with your mouth open? YesNoDo you have sleep apnea? YesNoDo you sleep with a CPAP? Check any of the following which you have had or have at present: Heart Failure Emphysema Aids Heart Disease or Attack Cough HIV Positive Angina Pectoris Tuberculosis (TB) Hepatitis A (infectious) High Blood Pressure Asthma Hepatitis B (serum) Heart Murmur Hay Fever Liver Disease Heart Pacemaker Sinus Trouble Rheumatic Fever Heart Surgery Blood Transfusion Drug Addiction Congenital Heart Lesions Diabetes Hemophilia Mitral Valve Prolapse Thyroid Disease Cold Sores Venereal Disease (Syphilis, Gonorrhea) Artificial Heart Valve X-Ray or Cobalt Treatment Allergies or Hives Cancer/Tumor Chemotherapy Arthritis Genital Herpes Artificial Joint Rheumatism Epilepsy or Seizures Anemia Cortisone Medicine Fainting or Dizzy Spells Stoke Glaucoma Nervousness Kidney Trouble Pain in Jaw Joints Psychiatric Treatment Ulcers Bruise Easily Sickle Cell Disease Scarlet Fever To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or change in medications, I will inform the office and doctor at the next appointment without fail. Signature of Patient, Parent or Guardian Submit Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office. Previous Next Request Your Complimentary Exam
