Adult Patient Form

Patients Name
What do you prefer to be called?
Patient GenderMaleFemaleOther

Date of birth
    Do you wish to receive appointment reminders?
 Email
 Text
 Both

Just like phone calls and voicemails, texting may not always be 100% secure depending on the mobile service you use. Knowing that, would you like us to communicate with you via text?
 Yes
 No
 
Approximate date of last appointment?
   

Name
Address (If different from above)
Town
StateAlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWest VirginiaWisconsinWyoming

Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Subscriber date of birth
       

 Secondary Dental Insurance

Subscriber's Name
Subscriber's Employer
Insurance Company
ID/Subscriber #
Subscriber date of birth
     

Primary Care Physician
Last Visit
   
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Have your tonsils or adenoids been removed?
 Yes
 No

Have you experienced jaw joint pain/discomfort? (TMJ/TMD)?
 Yes
 No

Do you have missing or extra permanent teeth?
 Yes
 No

Have you had an injury to?
 Teeth
 Mouth
 Chin

Have you had gum disease or periodontal treatment?
 Yes
 No

Have you ever taken medications for treatment of Osteoporosis? (Fosamax, Boniva, etc.)
 Yes
 No

Do you have any sensory processing issues?
 Yes
 No

(Women) Are you pregnant?
 Yes 
 No

Do you have speech problems?
 Yes
 No

Do you have any of the following habits?
 Clenching Teeth
 Lip Sucking/Biting
 Nail Biting
 Prolonged Bottle/Pacifier
 Grinding Teeth
 Mouth Breathing
 Tongue Thrusting
 Thumb/Finger Sucking


Do your gums bleed? 
 Yes
 No

Do you like your smile?
 Yes
 No
   

Name
Relationship to patient
Primary Phone