ADULT PATIENT INFORMATION
* All highlighed fields are required. Please type n/a if not applicable.
Date
How did you hear about us?
Patient's First Name
Patient's Last Name
Nickname
Age
Address
City
State
Zipcode
How long at this address?
Home Phone
Cell Phone
email
Birth Date
Sex
Height
Weight
In case of emergency, contact:
Name
Phone
Relationship to Patient
What are your hobbies?
In your own words describe your main orthodontic problem:
Your Employer
Occupation
How long at current employer?
business address
city
state
zipcode
Work Phone
Spouse's First Name
Spouse's Last Name
Cell Phone
Date of Birth
Spouse's Employer
Occupation
How long at current employer?
business address
city
state
zipcode
work phone
Please rank in order of importance your priority in choosing an orthodontic office. Please use each number only once.
Optimal orthodontic care and service:
3
2
1
Convenience / location of office:
3
2
1
Lowest cost for orthodontic care:
3
2
1
ORTHODONTIC INSURANCE INFORMATION
If you have orthodontic coverage, the following information is required for submitting an insurance claim. Please complete the entire section to ensure proper billing. Thank you.
Insured's Name
Insurance Company
Group Number
Policy/ID/Social Security #
Insurance Company Address
Phone Number
IS POLICY CONNECTED WITH YOUR UNION?
No
Yes
Name of Union:
Do you have dual coverage? If YES, please complete the following insurance info:
No
Yes
Insured's Name
Insurance Company
Group Number
Policy/ID/Social Security #
Insurance Company Address
Phone Number
IS POLICY CONNECTED WITH YOUR UNION?
No
Yes
Name of Union:
GENERAL INFORMATION
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
Address
Phone
Date of last dental check-up
Currently under treatment?
No
Yes
Medical Physician's Name
Address
Phone
Date of last check-up
Currently under treatment?
No
Yes
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 allergic to latex?
No
Yes
Are you in general good health at this time?
No
Yes
Are you under any medical treatment now?
No
Yes
Are you taking any drugs or medications?
No
Yes
If YES please specify:
Have you ever had any adverse response to any drugs, including penicillin?
No
Yes
If YES please specify:
Are you allergic to any known materials resulting in hives, asthma, eczema, etc.?
No
Yes
If YES please specify:
Have you ever had any major operations including hip/joint replacement?
No
Yes
If YES please specify:
Have any wounds healed slowly or presented other complications?
No
Yes
Have you ever had any radiation therapy or chemotherapy?
No
Yes
Have you ever had a serious accident involving head injuries?
No
Yes
Have you had a history of any of the following?
Yes
No
ASTHMA
Yes
No
CARDIOVASCULAR DISEASE
Yes
No
CANCER
Yes
No
HAY FEVER
Yes
No
HEART MURMUR
Yes
No
HERPES
Yes
No
SINUS PROBLEMS
Yes
No
RHEUMATIC FEVER
Yes
No
TUMOR OR GROWTH
Yes
No
RESPIRATORY PROBLEMS
Yes
No
BLOOD DISEASE
Yes
No
SEXUALLY TRANSMITTED DISEASE
Yes
No
TONSILLITIS
Yes
No
BONE DISORDER
Yes
No
EMOTIONAL PROBLEMS
Yes
No
DIZZINESS
Yes
No
AIDS OR HIV POSITIVE
Yes
No
EXCESSIVE BLEEDING
Yes
No
CONVULSIONS
Yes
No
IMMUNE SYSTEM PROBLEMS
Yes
No
FAINTING
Yes
No
EPILEPSY
Yes
No
INFECTIOUS DISEASE
Yes
No
HEPATITIS OR LIVER DISEASE
Yes
No
DIABETES
Yes
No
ARTHRITIS OR PAINFUL JOINTS
Yes
No
ALCOHOLISM
Yes
No
HEARING DISORDER
Yes
No
MIGRAINE HEADACHES
Yes
No
DRUG ABUSE
Yes
No
OTHER
OTHER Conditions not listed:
Do you snore?
No
Yes
Do you have unexplained awakenings from sleep?
No
Yes
Do you, or have you been told that you stop breathing for short periods during sleep?
No
Yes
Do you get excessively tired during the day and/or fall asleep when you should be awake?
No
Yes
Are you on a diet at this time?
No
Yes
Are you pregnant?
No
Yes
Have you ever smoked or used Tobacco products?
No
Yes
DENTAL 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.
When were your last full-mouth x-rays taken?
Where?
Do your gums bleed?
No
Yes
Have you ever had gum disease, or periodontal treatment?
No
Yes
Do you frequently get sore spots in your mouth?
No
Yes
Do you have any dental complaints at the present time?
No
Yes
Do you experience frequent headaches?
No
Yes
Do you have a history of back or neck injuries? Whiplash?
No
Yes
Do you have any clicking or popping of your jaw (TMJ)?
No
Yes
Do you have pain in or around your ears?
No
Yes
Does any part of your mouth hurt when clenched?
No
Yes
Do you habitually clench or grind your teeth during the night or day?
No
Yes
Do you have any history of lip sucking or biting?
No
Yes
Do you have any history of nail biting?
No
Yes
Do you have any history of thumb or finger sucking?
No
Yes
If YES, until what age?
Do you have any history of tongue thrusting?
No
Yes
Do you have any history of speech difficulty or speech therapy?
No
Yes
Are you a mouth breather?
No
Yes
Do you chew on only one side of your mouth?
No
Yes
If so, why?
Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc )?
No
Yes
If so, where?
Have you ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?
No
Yes
Have you ever taken medication for treatment of Osteoporosis?
No
Yes
If yes, indicate medicated dosage?
Release and Waiver (HIPAA)
I authorize the dentist to release any information including the diagnosis and the records of any treatment or examinations rendered to my child during the period of such orthodontic care to third party payers and/ or health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services, and I am responsible for any benefit not paid by insurance or difference in cost due to lapse in coverage. I agree to be responsible for payment of all services rendered on my child's behalf. I understand that providing incorrect information can be dangerous to my child's health. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child's medical or dental health. I understand that the initial exam with Dr. Zuch is of no charge, and any succeeding services such as pre treatment diagnostics are rendered at additional cost. I have read/reviewed The Tooth Mover's complete
HIPPA policy
at
http://www.mytoothmover.com.
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 OF PATIENT
date
DOCTOR SIGNATURE
date
or
If you choose to print, be sure to bring the printed form with you on your first visit.
