Adult New Patient Information

Patient Information

Patient Name *

Gender

Male Female

Social Security Number

Birth Date

Drivers License Number

Home Address

City

State

Zip

Primary Phone Number
Primary Phone Number

 

Phone Type

Home Cell  

Secondary Phone Number
Secondary Phone Number

 

Phone Type

Home Cell Other

E-mail Address *

Employer's Name

Occupation

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Spouse/Emergency Contact Information

Marital Status

Single Married Divorced Widowed Significant Other

Person(s) OK to release appointment or medically related information to concerning you.

Relation

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Dental Insurance Information

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Dental History

General Dentist

Last Visit

How did you hear about our Practice?

Ad Internet Family or Friend Physician Other

Name of person referring (if applicable)


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

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 you like your smile?

Yes No

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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 allergies:

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

 

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