Adult Patient Form

First Name
Patient Birthdate
 

 Check if the patient is also the person who will be financially responsible for treatment.

First Name
Birthdate
     

Insurance Information

First Insurance

   
Patient's DOB
   
Subscriber's Birthdate
               

Secondary Insurance

 
Subscriber's Birthdate
               

Dentist Name
Check-up FrequencyOnce Per YearTwice Per YearMore Than Twice Per YearNeverEmergencies Only

Last Dental Visit
 

Has the patient had an orthodontic consult or treatment?
 Yes
 No

If so, when?
   
​​​
Please select YES if the patient has had any of the conditions listed below either now or in the past.

Speech problems/therapy?
 Yes
 No

Grind or clench teeth?
 Yes
 No

Injury to face, jaw, teeth or mouth?
 Yes
 No

Discomfort from teeth or gums?
 Yes
 No

Pain, tenderness or noise in either jaw?
 Yes
 No

Frequent headaches?
 Yes
 No

Oral habits (thumb/finger sucking, lip/nail biting)?
 Yes
 No

Neck/shoulder pain?
 Yes
 No

Frequent sore throats?
 Yes
 No

Brush teeth daily?
 Yes
 No

Floss teeth daily?
 Yes
 No

Fluoride treatments?
 Yes
 No

Mouth breathing?
 Yes
 No

Snores during sleep?
 Yes
 No

Requires premedication?
 Yes
 No

Any missing or extra permanent teeth?
 Yes
 No

Apprehensive about dental care?
 Yes
 No

Frequently Chew Gum?
 Yes
 No
 

Physician Name
Date of Last Physical
   
​​​​​​            
Please select YES if the patient has had any of the conditions listed below either now or in the past.

Rheumatic Fever
 Yes
 No

Tuberculosis/Lung Disease
 Yes
 No

Pneumonia
 Yes
 No

Liver Disease 
 Yes
 No

Kidney Disease
 Yes
 No

Heart Attack/Stroke
 Yes
 No

Heart Disease
 Yes
 No

Congenital Heart Defect
 Yes
 No

Heart Murmur
 Yes
 No

Hemophilia
 Yes
 No

Hypertension/High Blood Pressure
 Yes
 No

Prolonged Bleeding/Transfusion
 Yes
 No

Anemia
 Yes
 No

HIV/AIDS
 Yes
 No

Hepatitis
 Yes
 No

Tonsils/Adenoids Removed
 Yes
 No

Cancer
 Yes
 No

Family History of Cancer
 Yes
 No

Received Radiation Treatment
 Yes
 No

Growth Problems
 Yes
 No

Endocrine Problems
 Yes
 No

Hormone Therapy
 Yes
 No ​​​​​

Latex/Metal Allergy
 Yes
 No

Nervous Disorders
 Yes
 No

Bone Disorders/Bone Loss
 Yes
 No

Diabetes
 Yes
 No

Seizures/Epilepsy
 Yes
 No

Handicaps/Disabilities
 Yes
 No

Asthma
 Yes
 No

Arthritis
 Yes
 No

Treated for Emotional Problems
 Yes
 No

Ever Been Hospitalized
 Yes
 No

Take Bisphosphonates (Fosamax, Boniva)
 Yes
 No
 

 

HIPAA is a federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practices is to explain how Shine Orthodontics may use or disclose your protected health care information. The Notice also explains the rights that you are guaranteed under HIPAA regulations. Our Notice of Privacy Practices is available for you to view on our website, www.shineorthonc.com, or a copy can be obtained by contacting our office. Signing below indicates that you have had the opportunity to review the Notice of Privacy Practices.

I certify that I have had the opportunity to review the Notice of Privacy Practices of Shine Orthodontics.
   
Signature:
Date: