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Patient Forms (Adults)
Patient
Date
Patient’s last name
*
First name
*
Middle initial
Title
*
Mr.
Mrs.
Ms.
Miss.
Dr.
I prefer to be called
Birth date
Sex
Male
Female
Social Security #
Marital Status
Single
Married
Separated
Divorced
Widowed
Home address
City, State, Zip code
Home phone
Cell phone
Work phone
Email Address(es)
Occupation
Employer
Closest Relative
Spouse or closest relatives name(s)
Title
Mr.
Mrs.
Ms.
Miss.
Dr.
Relationship to patient
Address (if different than patient address)
Home Phone (If different)
Cell phone
Work phone
Dentist
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen: Name
City, State
Physician
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
Name
City, State
Reason
General Information
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you had any previous orthodontic treatment? Please describe.
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account? _
Address (if different than page 1)
City, State, Zip
Home phone
Cell phone
Email address(es)
Social Security #
Employer
Dental Insurance
Primary policy holder’s full name
Birth date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
Secondary policy holder’s full name
Birth date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
Medical Insurance
Policy holder’s full name
Insurance Company
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Medical History
Now or in the past, have you had:
Birth defects or hereditary problems?
Yes
No
DK/U
Bone fractures or major injuries?
Yes
No
DK/U
Any injuries to face, head, neck?
Yes
No
DK/U
Arthritis or joint problems?
Yes
No
DK/U
Endocrine or thyroid problems?
Yes
No
DK/U
Diabetes or low sugar?
Yes
No
DK/U
Kidney problems?
Yes
No
DK/U
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
DK/U
Stomach ulcer, hyperacidity, acid reflux?
Yes
No
DK/U
Immune system problems?
Yes
No
DK/U
History of osteoporosis?
Yes
No
DK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
DK/U
AIDS or HIV positive?
Yes
No
DK/U
Hepatitis, jaundice, or other liver problems?
Yes
No
DK/U
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
DK/U
Seizures, fainting spells, neurologic problems?
Yes
No
DK/U
Mental health disturbance or depression?
Yes
No
DK/U
Vision, hearing, or speech problems?
Yes
No
DK/U
History of eating disorder (anorexia, bulimia)?
Yes
No
DK/U
High or low blood pressure?
Yes
No
DK/U
Excessive bleeding or bruising, anemia?
Yes
No
DK/U
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
DK/U
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
DK/U
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
DK/U
Skin disorder (other than common acne)?
Yes
No
DK/U
Do you eat a well-balanced diet?
Yes
No
DK/U
Frequent headaches or migraines?
Yes
No
DK/U
Frequent ear infections, colds, throat infections?
Yes
No
DK/U
Asthma, sinus problems, hayfever?
Yes
No
DK/U
Tonsil or adenoid condition?
Yes
No
DK/U
Do you frequently breathe through your mouth?
Yes
No
DK/U
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Yes
No
DK/U
Latex (gloves, balloons)
Yes
No
DK/U
Aspirin
Yes
No
DK/U
Metals (jewelry, clothing snaps)
Yes
No
DK/U
Penicillin
Yes
No
DK/U
Other antibiotic
Yes
No
DK/U
Ibuprofen (Motrin, Advil)
Yes
No
DK/U
Acrylics
Yes
No
DK/U
Plant pollens
Yes
No
DK/U
Animals
Yes
No
DK/U
Foods
Yes
No
DK/U
Other substances
Dental History
Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?
Yes
No
DK/U
Supernumerary (extra) or congenitally missing teeth?
Yes
No
DK/U
Chipped or injured primary or permanent teeth?
Yes
No
DK/U
Any sensitive or sore teeth?
Yes
No
DK/U
Bleeding gums, bad taste or mouth odor?
Yes
No
DK/U
Jaw fractures, cysts, infections?
Yes
No
DK/U
Any teeth treated with root canals or pulpotomies?
Yes
No
DK/U
“Gum boils,” frequent canker sores or cold sores?
Yes
No
DK/U
History of speech problems or speech therapy?
Yes
No
DK/U
Difficulty breathing through nose?
Yes
No
DK/U
Food impaction between the teeth?
Yes
No
DK/U
Mouth breathing habit or snoring at night?
Yes
No
DK/U
Frequent oral habits (sucking finger, chewing pen, etc)?
Yes
No
DK/U
Teeth causing irritation to lip, cheek or gums?
Yes
No
DK/U
Abnormal swallowing (tongue thrust)?
Yes
No
DK/U
Tooth grinding or clenching?
Yes
No
DK/U
Clicking, locking in jaw joints?
Yes
No
DK/U
Soreness in jaw muscles or face muscles?
Yes
No
DK/U
Ringing in ears, difficulty in chewing or opening jaw?
Yes
No
DK/U
Have you ever been treated for “TMJ” or “TMD” problems?
Yes
No
DK/U
Any broken or missing fillings?
Yes
No
DK/U
Any serious trouble associated with previous dental treatment?
Yes
No
DK/U
Have you ever been diagnosed with gum disease or pyorrhea?
Yes
No
DK/U
Have you ever had an orthodontic consultation or treatment before now?
Yes
No
DK/U
Patient Health Information
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you take antibiotic pre-medication before any dental procedures?
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?
Yes
No
Are you trying to become pregnant?
Yes
No
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
Release and Waiver
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company
Signature
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her 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 medical or dental health.
Signature
Date
Medical History Updates or Changes
Changes
Signature
Date
Dental Staff Signature
Date
Changes
Signature
Date
Dental Staff Signature
Date
Changes
Signature
Date
Dental Staff Signature
Date
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:
Patient
Date
Patient’s last name
*
First name
*
Middle initial
Title
*
Mr.
Mrs.
Ms.
Miss.
Dr.
I prefer to be called
Birth date
Sex
Male
Female
Social Security #
Marital Status
Single
Married
Separated
Divorced
Widowed
Home address
City, State, Zip code
Home phone
Cell phone
Work phone
Email Address(es)
Occupation
Employer
Closest Relative
Spouse or closest relatives name(s)
Title
Mr.
Mrs.
Ms.
Miss.
Dr.
Relationship to patient
Address (if different than patient address)
Home Phone (If different)
Cell phone
Work phone
Dentist
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen: Name
City, State
Physician
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
Name
City, State
Reason
General Information
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you had any previous orthodontic treatment? Please describe.
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account? _
Address (if different than page 1)
City, State, Zip
Home phone
Cell phone
Email address(es)
Social Security #
Employer
Dental Insurance
Primary policy holder’s full name
Birth date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
Secondary policy holder’s full name
Birth date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?
Yes
No
Don’t Know
Medical Insurance
Policy holder’s full name
Insurance Company
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Medical History
Now or in the past, have you had:
Birth defects or hereditary problems?
Yes
No
DK/U
Bone fractures or major injuries?
Yes
No
DK/U
Any injuries to face, head, neck?
Yes
No
DK/U
Arthritis or joint problems?
Yes
No
DK/U
Endocrine or thyroid problems?
Yes
No
DK/U
Diabetes or low sugar?
Yes
No
DK/U
Kidney problems?
Yes
No
DK/U
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
DK/U
Stomach ulcer, hyperacidity, acid reflux?
Yes
No
DK/U
Immune system problems?
Yes
No
DK/U
History of osteoporosis?
Yes
No
DK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
DK/U
AIDS or HIV positive?
Yes
No
DK/U
Hepatitis, jaundice, or other liver problems?
Yes
No
DK/U
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
DK/U
Seizures, fainting spells, neurologic problems?
Yes
No
DK/U
Mental health disturbance or depression?
Yes
No
DK/U
Vision, hearing, or speech problems?
Yes
No
DK/U
History of eating disorder (anorexia, bulimia)?
Yes
No
DK/U
High or low blood pressure?
Yes
No
DK/U
Excessive bleeding or bruising, anemia?
Yes
No
DK/U
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
DK/U
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
DK/U
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
DK/U
Skin disorder (other than common acne)?
Yes
No
DK/U
Do you eat a well-balanced diet?
Yes
No
DK/U
Frequent headaches or migraines?
Yes
No
DK/U
Frequent ear infections, colds, throat infections?
Yes
No
DK/U
Asthma, sinus problems, hayfever?
Yes
No
DK/U
Tonsil or adenoid condition?
Yes
No
DK/U
Do you frequently breathe through your mouth?
Yes
No
DK/U
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Yes
No
DK/U
Latex (gloves, balloons)
Yes
No
DK/U
Aspirin
Yes
No
DK/U
Metals (jewelry, clothing snaps)
Yes
No
DK/U
Penicillin
Yes
No
DK/U
Other antibiotic
Yes
No
DK/U
Ibuprofen (Motrin, Advil)
Yes
No
DK/U
Acrylics
Yes
No
DK/U
Plant pollens
Yes
No
DK/U
Animals
Yes
No
DK/U
Foods
Yes
No
DK/U
Other substances
Dental History
Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?
Yes
No
DK/U
Supernumerary (extra) or congenitally missing teeth?
Yes
No
DK/U
Chipped or injured primary or permanent teeth?
Yes
No
DK/U
Any sensitive or sore teeth?
Yes
No
DK/U
Bleeding gums, bad taste or mouth odor?
Yes
No
DK/U
Jaw fractures, cysts, infections?
Yes
No
DK/U
Any teeth treated with root canals or pulpotomies?
Yes
No
DK/U
“Gum boils,” frequent canker sores or cold sores?
Yes
No
DK/U
History of speech problems or speech therapy?
Yes
No
DK/U
Difficulty breathing through nose?
Yes
No
DK/U
Food impaction between the teeth?
Yes
No
DK/U
Mouth breathing habit or snoring at night?
Yes
No
DK/U
Frequent oral habits (sucking finger, chewing pen, etc)?
Yes
No
DK/U
Teeth causing irritation to lip, cheek or gums?
Yes
No
DK/U
Abnormal swallowing (tongue thrust)?
Yes
No
DK/U
Tooth grinding or clenching?
Yes
No
DK/U
Clicking, locking in jaw joints?
Yes
No
DK/U
Soreness in jaw muscles or face muscles?
Yes
No
DK/U
Ringing in ears, difficulty in chewing or opening jaw?
Yes
No
DK/U
Have you ever been treated for “TMJ” or “TMD” problems?
Yes
No
DK/U
Any broken or missing fillings?
Yes
No
DK/U
Any serious trouble associated with previous dental treatment?
Yes
No
DK/U
Have you ever been diagnosed with gum disease or pyorrhea?
Yes
No
DK/U
Have you ever had an orthodontic consultation or treatment before now?
Yes
No
DK/U
Patient Health Information
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you take antibiotic pre-medication before any dental procedures?
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?
Yes
No
Are you trying to become pregnant?
Yes
No
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
Release and Waiver
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company
Signature
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her 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 medical or dental health.
Signature
Date
Medical History Updates or Changes
Changes
Signature
Date
Dental Staff Signature
Date
Changes
Signature
Date
Dental Staff Signature
Date
Changes
Signature
Date
Dental Staff Signature
Date
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection - <strong>please leave it blank</strong>:
