Adult Patient Form Please click here to download the .pdf version. Step 1 of 2 50% Whom may we thank for referring you to our office?Patient InformationPatient’s Last Name First Middle Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Preferred NameDate of Birth Date Format: MM slash DD slash YYYY AgeGenderFemaleMaleEmployed ByWork NumberBusiness Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationMarital StatusSingleMarriedWidowedSeparatedDivorcedSpouse or Responsible PartyName First Last Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Responsible Party SSN:PhoneEmployed ByWork PhoneBusiness Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OccupationEmail In case we can't reach you, who is the best person to call? Please include a phone number they can be reached at.InsuranceDo you have dental insurance that covers orthodontic treatment?YesNoIf yes, a copy of your insurance card is required. Insurance is filed from this office by mail, fax or electronically. Health HistoryPlease check next any medical or dental conditions you may hav below. Please check all that apply.* Birth defects or hereditary problems Bone fractures or any major accidents Rheumatoid or arthritic conditions Endocrine or thyroid problem Kidney problem Diabetes Cancer or previous cancer treatment Stomach or hyperacidity Polio, mono, tuberculosis or pneumonia Problems of the immune system AIDS or HIV positive Hepatitis, jaundice or liver problems Fainting spell, siezures, epilepsy or neurologic problems Mental health or behavioral problems Vision, hearing, tasting or speech difficulties Excessive bleeding, black and blue tendency, anemia or bleeding disorder High or low blood pressure Cardiovascular problem (murmur, hear trouble, repaired heart valve, stroke, inborn heart defects or rheumatic heart) Skin disorder Eye, ear, nose or throat condition Tonsil or adenoid conditions Pregnant Taking Birth Control Pills Other physical problems or symptoms Please list any medications you are currently taking.Please list any drugs you are allergic to.Do you take antibiotics prior to dental care?Who is your primary care physician? Please include a phone number.Dental history: Please check all that apply below. Permanent or "extra" teeth removed or congenitally missing teeth. Chipped or otherwise injured baby or permanent teeth Teeth sensitive to hot, cold; teeth throb or ache Jaw fractures, cysts or mouth infections Root canals treated teeth Bleeding gums or periodontal disease Frequent fever blisters, canker sores or cold sores Thumb or finger sucking habit Mouth breathing or difficulty in breathing Clicking or locking jaw Pain in jaw or ringing in ears Any pain or soreness in the muscles of the face or around the ears Difficulty in chewing or jaw opening Previously treated for “TMJ” problems (your jaw-joint and facial muscle pain) Previous orthodontic treatment or worn a “retainer” Previous periodontal (gum) treatment Aware or concerned about under or over developing jaw relationship Relative with similar tooth or jaw relationship Serious trouble associated with any previous dental treatment Prior orthodontic examination or treatment Name of Patient's DentistDate or most recent dental examination. Date Format: MM slash DD slash YYYY Additional information/follow-up to questions?What is your primary orthodontic concern?Realizing that successful treatment greatly depends upon the patient’s complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene; are there any restrictions , handicaps or problems that might be encountered during treatment?Notice or Privacy Practices* I have read and understand the above questions. 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. If there are changes later to this history record or medical/dental status I will so inform this practice.
