Adult Patient Form

PATIENT INFORMATION









BIRTH DATE
 







SPOUSE INFORMATION











DOB

INSURANCE INFORMATION






IS POLICY CONNECTED WITH YOUR UNION?



Does the patient have DUAL COVERAGE? If yes, please complete the following secondary insurance info: 








IS POLICY CONNECTED WITH YOUR UNION?

GENERAL INFORMATION







DATE OF LAST DENTAL CHECK-UP


CURRENTLY UNDER TREATMENT?


 


DATE OF LAST CHECK-UP


CURRENTLY UNDER TREATMENT?


​​

ANY HISTORY OF:





 

MEDICAL HISTORY

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

Is the patient in general good health at this time?



Is the patient under any medical treatment now?



Is the patient taking any drugs or medications?



Has the patient ever had any adverse response to any drugs, including penicillin?



Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.?



Is the patient allergic to latex?



Has the patient ever had any major operations including hip/joint replacement?



Does the patient have any wounds that healed slowly or presented other complications?



Has the patient had any radiation therapy or chemotherapy?



Has the patient had a serious accident involving head injuries?



Has the patient had a history of any of the following?
































Does the patient snore?



Does the patient have unexplained awakenings from sleep?



Does the patient stop breathing for short periods during sleep?



Does the patient get excessively tired during the day and/or fall asleep when they should be awake?



Is the patient on a diet at this time?



Does the patient have a history of fainting?



Is the patient pregnant?



Has the patient ever smoked or used Tobacco products?

DENTAL HISTORY

The following information is requested to enable us to give the patient the best consideration of their orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

When were the patient's last full-mouth x-rays taken?
 

Do the patient's gums bleed?



Has the patient ever had gum disease, or periodontal treatment?



Does the patient frequently get sore spots in their mouth?



Does the patient have any dental complaints at the present time?



Does the patient experience frequent headaches?



Does the patient have a history of back or neck injuries? Whiplash?



Does the patient have any clicking or popping of their jaw (TMJ)?



Does the patient have pain in or around their ears?



Does any part of the patient's mouth hurt when clenched?



Does the patient habitually clench or grind their teeth during the night or day?



Does the patient chew on only one side of their mouth?


 

Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )?


 

Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?



Has the patient ever taken medication for treatment of Osteoporosis?


 

PURPOSE OF CONSENT (HIPAA)

By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.

SIGNATURE:
DATE:


If you would like a copy for your personal records, please request one in our office.