Required fields *
ALL fields are strongly encouraged
ADULT PATIENT INFORMATION
Full Legal Name
Preferred Name
Date
Date of Birth
Sex at birth
Male
Female
Preferred Pronouns
Height
Weight
Address
City
Zipcode
Cell Phone
Email
Occupation
Employed By
Spouse's Name
Date of Birth
Occupation
Employed By
Has anyone in your family had orthodontic work done in our office?
Who referred you? / How did you hear about our office?
What are your reasons for seeking an orthodontic consultation? / What would you like us to do for you?
Patient's Dentist
Last Dental Check-up
INSURANCE INFORMATION
Your insurance benefits are a contract between you and your carrier. However, with your permission, we would be happy to assist you in obtaining your benefits. Please complete the following as completely as you can, so we can be as helpful as possible.
Do you have dental and/or orthodontic insurance coverage?
Primary Dental Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
Secondary Dental Insurance Co.
Group #
Phone #
Subscriber is
Subscriber Date of Birth
Subscriber ID
HEALTH HISTORY
Your health is important to us. In order to provide excellent care with safety, it is necessary to become acquainted with vital information related to each patient. Thus, it is extremely important that you answer the following questions as accurately as possible. If you have any questions regarding the information requested, please feel free to ask the doctor or a member of the staff for assistance.
Have you been a patient in a hospital during the past 2 years?
Yes
No
Have you been under the care of a physician during the past 2 years?
Yes
No
Please list any kind of medicine or drugs you have taken during the past 2 years.
Are you allergic to Penicillin(s) / Do you have any other allergies or sensitivities? If yes, please list them.
Do you have a latex allergy?
Yes
No
Have you had any excessive bleeding requiring special treatment?
Yes
No
List any serious medical condition(s)
Have you taken any bisphosphonates or osteoporosis / bone cancer meds. within last 5 years?
Yes
No
Do you smoke? If yes, how much?
Do you have diabetes?
Yes
No
Do you have hypertension (high blood pressure)?
Yes
No
Do you have high cholesterol?
Yes
No
Is there a possibility that you are pregnant? If so, how many months?
>>> Are you nursing?
Yes
No
Do you have ADHD?
Yes
No
>>> Any part of the Autism spectrum?
Yes
No
Have you ever tested HIV positive?
Yes
No
Do you snore?
Yes
No
Have you been told that you stop breathing when you are sleeping?
Yes
No
Do you suffer from frequent or severe headaches?
Yes
No
>>> Back pain? / Neck pain?
Do you have any other health history or Medical Conditions we did not ask about? If yes, please explain?
Physician's Name, City, and Phone Number
Your "Smile" Questionaire
Have you had any accidents involving your teeth?
Yes
No
Have you ever had an injury to your face, neck or jaws?
Yes
No
Do you have difficulty in opening your mouth wide?
Yes
No
Do your jaws ever click or pop?
Yes
No
Do you have pain in front of the ears?
Yes
No
Do you have any pre-existing T.M.J. problems?
Yes
No
Check habits
Nail Biting
Yes
No
Thumbsucking
Yes
No
Mouthbreathing
Yes
No
Lip Biting
Yes
No
Pencil Biting
Yes
No
Night Grinding
Yes
No
Other
Have you ever had any difficulty with past dental treatment? Please explain
Do you feel that your teeth are...
Too small or short?
Yes
No
Crooked or crowded?
Yes
No
Too large or too long?
Yes
No
Misshaped (uneven Pointed)?
Yes
No
Off Color?
Yes
No
Does your teeth 'stick out too much'?
Yes
No
Are there spaces between your teeth that you do not like?
Yes
No
Does too much gum tissue show when you smile?
Yes
No
Does too little gum tissue show when you smile?
Yes
No
Have you had previous orthodontic treatment (including braces or other appliances?) If so, when and by whom?
Are there other dental issues not listed above that you would like to discuss or have treated? Please explain.
The above medical history is accurate and current to the best of my knowledge. I understand I need to notify this office whenever there is a change in my health history.
Name of person filling out this form
Date
Submit