Adult Patient Form

NUMBER OF CHILDREN IN THE FAMILY
NAME OF ANY FAMILY MEMBER IN TREATMENT OR PREVIOUSLY WITH US
NAME OF PREVIOUS ORTHODONTIST
GENERAL DENTIST'S NAME
GENERAL DENTIST'S ADDRESS
GENERAL DENTIST'S PHONE
DATE OF LAST DENTAL CHECK-UP

CURRENTLY UNDER TREATMENT?
 YES
 NO
 
DATE OF LAST CHECK-UP

CURRENTLY UNDER TREATMENT?
 YES
 NO
​​

ANY HISTORY OF:
 Thumb or finger sucking
 Grinding of teeth
 Frequent headaches or jaw pain
 Difficulty eating any foods
 Speech difficulty or speech therapy
 

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?
 YES
 NO

Is the patient under any medical treatment now?
 YES
 NO

Is the patient taking any drugs or medications?
 YES
 NO

If yes, please list medications:
Has the patient ever had any adverse response to any drugs, including penicillin?
 YES
 NO

Is the patient allergic to any known materials resulting in hives, asthma, eczema, etc.?
 YES
 NO

Is the patient allergic to latex?
 YES
 NO

Has the patient ever had any major operations including hip/joint replacement?
 YES
 NO

Does the patient have any wounds that healed slowly or presented other complications?
 YES
 NO

Has the patient had any radiation therapy or chemotherapy?
 YES
 NO

Has the patient had a serious accident involving head injuries?
 YES
 NO

Has the patient had a history of any of the following?
 ASTHMA
 HEART MURMUR
 TUMOR OR GROWTH
 TONSILLITIS
 AIDS OR HIV POSITIVE
 FAINTING
 DIABETES
 MIGRAINE HEADACHES
 CARDIOVASCULAR DISEASE
 HERPES
 RESPIRATORY PROBLEMS
 BONE DISORDER
 EXCESSIVE BLEEDING
 EPILEPSY
 ARTHRITIS OR PAINFUL JOINTS
 DRUG ABUSE
 CANCER
 SINUS PROBLEMS
 BLOOD DISEASE
 EMOTIONAL PROBLEMS
 CONVULSIONS
 INFECTIOUS DISEASE
 ALCOHOLISM
 HAY FEVER
 RHEUMATIC FEVER
 SEXUALLY TRANSMITTED DISEASE
 DIZZINESS
 IMMUNE SYSTEM PROBLEMS
 HEPATITIS OR LIVER DISEASE
 HEARING DISORDER

OTHER Conditions not listed:
Does the patient snore?
 YES
 NO

Does the patient have unexplained awakenings from sleep?
 YES
 NO

Does the patient stop breathing for short periods during sleep?
 YES
 NO

Does the patient get excessively tired during the day and/or fall asleep when they should be awake?
 YES
 NO

Is the patient on a diet at this time?
 YES
 NO

Does the patient have a history of fainting?
 YES
 NO

Is the patient pregnant?
 YES
 NO

Has the patient ever smoked or used Tobacco products?
 YES
 NO

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?
 YES
 NO

Has the patient ever had gum disease, or periodontal treatment?
 YES
 NO

Does the patient frequently get sore spots in their mouth?
 YES
 NO

Does the patient have any dental complaints at the present time?
 YES
 NO

Does the patient experience frequent headaches?
 YES
 NO

Does the patient have a history of back or neck injuries? Whiplash?
 YES
 NO

Does the patient have any clicking or popping of their jaw (TMJ)?
 YES
 NO

Does the patient have pain in or around their ears?
 YES
 NO

Does any part of the patient's mouth hurt when clenched?
 YES
 NO

Does the patient habitually clench or grind their teeth during the night or day?
 YES
 NO

Does the patient chew on only one side of their mouth?
 YES
 NO
 
Are any parts of the patient's mouth sore to pressure or irritants (cold, sweets, etc )?
 YES
 NO
 
Has the patient ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?
 YES
 NO

Has the patient ever taken medication for treatment of Osteoporosis (such as biophosphanate or other calcium medication)?
 YES
 NO
 

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.