ADULT PATIENT INFORMATION
Personal Information
Patient First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Email:
Birthdate:
Age:
Gender:
Male
Female
Other
Employed By:
Occupation:
Business Phone:
Business Address:
Hobbies & Interests:
Spouse's Name:
Date of Birth:
Email:
Employed By:
Occupation:
Business Address:
Cell Phone:
Business Phone:
Whom may we thank for referring you?
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Legal First Name:
Middle Initial:
Last Name:
Birthdate:
Social Security Number:
Employer:
Occupation:
Employer Address:
Employer Phone:
Insurance Information
Primary Dental Insurance Information
Patients' Relationship To Subscriber:
Full Legal Name of Insured Subscriber:
Date of Birth:
Social Security Number:
Insurance Company Information
Insurance Company Name:
Group Number:
Identification Number:
Address of Insurance Company:
City:
State:
Zip:
Phone Number of Insurance Company:
Secondary Dental Insurance Information
Patients' Relationship To Subscriber:
Full Legal Name of Insured Subscriber:
Date of Birth:
Social Security Number:
Insurance Company Information
Insurance Company Name:
Group Number:
Identification Number:
Address of Insurance Company:
City:
State:
Zip:
Phone Number of Insurance Company:
Medical History
Dentist Name:
Physician Name:
Latex Allergy?
No
Yes
Anemia?
No
Yes
Diabetes?
No
Yes
Fainting/Dizziness?
No
Yes
Hepatitis?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Liver Involvement?
No
Yes
Asthma?
No
Yes
Endocrine problems?
No
Yes
Glaucoma?
No
Yes
HIV or AIDS?
No
Yes
Nervous disorders?
No
Yes
Rheumatic fever?
No
Yes
Bone disorders?
No
Yes
Epilepsy?
No
Yes
Heart trouble?
No
Yes
Kidney Involvement?
No
Yes
Pneumonia?
No
Yes
Tuberculosis?
No
Yes
List any drugs or medications now being taken:
History of allergies or drug sensitivity (specify):
(FEMALES) Pregnancy?
No
Yes
Are you taking birth control pills?
No
Yes
Have you ever smoked, vaped or chewed tobacco?
No
Yes
Dental History
Have there been any injuries to the face, mouth, or teeth?
No
Yes
Does the patient have any speech problems?
No
Yes
Have you been informed of any missing or extra permanent teeth?
No
Yes
Has an orthodontist been consulted previously?
No
Yes
Has the patient been diagnosed with sleep apnea?
No
Yes
Do you have any type of thumb or tongue habit?
No
Yes
Are you a mouth breather?
No
Yes
Have you ever seen an orthodontist?
No
Yes
If yes, who and when?
What is your attitude toward receiving orthodontic treatment?
No
Yes
Has anyone in your family received orthodontic treatment?
No
Yes
How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
No
Yes
Are you aware of your jaw clicking or popping?
No
Yes
Are you aware of clenching your teeth during the day?
No
Yes
Have you ever been told that you grind your teeth?
No
Yes
Do you have "tension" headaches?
No
Yes
Have you ever experienced chronic ringing in your ears?
No
Yes
Are you aware that some appointments will be during work hours?
No
Yes
Please list any fears or disabilities so we can help make your appointments more comfortable.
What are you most interested in today?
Braces
Clear Aligners
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth. in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases Teeth change throughout our lifetime and here can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Marshall to perform a complete orthodontic evaluation.
Signature:
Date: