Adult New Patient Information

Patient Information

* Patient Name: (Required)

Gender

Male Female

Social Security Number: Birth Date: Driver License:
Home Address: City: State: Zip:

Primary Phone:

home cell

Name of Mobile Phone Carrier Ok to leave message? Yes No

Secondary Phone:

home cell other

Name of Mobile Phone Carrier Ok to leave message? Yes No

E-mail: Employer's Name: Occupation:

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Spouse / Partner Information

Marital Status

Single Married Divorced Widowed Significant Other

Spouse/Partner's Name:
Emergency Contact Name: Phone Number: Relation: Address: City: State: Zip:

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Insurance Information

Primary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth:
Employer: Work Phone Number: {C}Secondary Insurance Company: Phone Number: Group Number: Policy Number: Member ID Number: Policy Holder's Name: Relation: Policy Holder's SSN: Policy Holder's Date of Birth:
Employer: Work Phone Number:

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Dental History

General Dentist:

Last Visit:

How did you hear about our Practice?

Ad Internet Family/Friend Physician Other
Name of person referring (if applicable) :

What are the main concerns you would like orthodontics to accomplish?

Concerns:

Is a family member currently in treatment?

Yes No

Has a family member received treatment in our office?

Yes No

Have you visited an orthodontist before?

Yes No
When: Reason:

Have your tonsils or adenoids been removed?

Yes No

Have you ever experienced jaw joint pain/ discomfort (TMJ/TMD)?

Yes No

Do you have any missing or extra permanent teeth?

Yes No

Have you ever had an injury to (select all that apply):

Teeth Mouth Chin

Do you have speech problems?

Yes No
If so, explain:

Do your gums bleed?

Yes No

Do you smoke?

Yes No

Do you like your smile?

Yes No

Do you currently or have you ever had any of the following habits (check all that apply)

Clenching/Grinding Teeth
Lip Sucking/Biting
Mouth Breathing
Nail Biting
Thumb/Finger Sucking
Chewing/Eating Problem

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Medical History

Are you currently being treated by a physician?

Yes No
Reason: Physician: Last Visit: Phone:

Do you have any allergies/sensitivities to medications or latex?

Yes No
If yes, please list:

Are you currently taking any prescription or over-the-counter medications?

Yes No
Please list, with dosage:

Have you had any serious illnesses or operations? If yes, describe:

Have you ever had a blood transfusion?

Yes NoIf yes, give approximate dates:

(Women) Are you pregnant?

Yes NoNursing? Yes NoTaking birth control pills? Yes No

Check if you have or have ever had any of the following:

Anemia Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems

Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Epilepsy Fainting Glaucoma Headaches Heart Murmur Heart Problems Hemophilia

Hepatitis High Blood Pressure HIV/AIDS Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever

Scarlet Fever Shortness of Breath Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsilitis Tuberculosis Ulcer Venereal Disease (STD)

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