FOR ADULT: WELCOME TO OUR PRACTICE
Patient Information
First Name:
Middle Initial:
Last Name:
SSN:
DOB:
Age:
Preferred Name:
E-mail:
Gender assigned at birth:
Male
Female
Choose not to disclose
Address:
City:
State:
Zip:
How long at this address?
Previous Address
(if less than 3 years)
:
Phone:
Cell:
Work:
Employer:
Occupation:
Years Employed:
Relationship Status:
Single
Married
Separated
Divorced
Widowed
Other:
Hobbies/Interests:
Name of General Dentist:
Phone:
Name of other family members treated at Orthdontics LTD:
Whom may we thank for referring you?
Additional Responsible Party Information -
If Applicable
(i.e. Step-Parent, Legal Guardian)
Name:
Relationship:
DOB:
SSN:
Employer:
Occupation:
Yrs Employed:
Address:
City:
State:
Zip:
E-mail:
Phone:
Cell:
Primary Dental Insurance
Insurance Co. Name:
Insurance Phone:
Group/Policy #:
SSN/ID#:
Insured's Name:
Relationship to Patient:
Insured's DOB:
Insured's Employer:
Secondary Dental Insurance
Insurance Co. Name:
Insurance Phone:
Group/Policy #:
SSN/ID#:
Insured's Name:
Relationship to Patient:
Insured's DOB:
Insured's Employer:
Emergency Contact Information
Nearest Relative Not Living with You:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Complete Address:
Do you authorize Orthodontics Ltd. to obtain a consumer credit report when appropriate?
I
AUTHORIZE
ORTHODONTICS LTD. TO OBTAIN A CONSUMER CREDIT REPORT WHEN APPROPRIATE.
I
DO NOT
AUTHORIZE ORTHODONTICS LTD. TO OBTAIN A CONSUMER CREDIT REPORT.
SIGNATURE OF PATIENT/GUARDIAN:
DATE:
Patient Dental/Medical History
Reason for visit?
Do you like your smile?
Are you currently in pain?
Yes
No
Explain:
Your current dental health is:
Good
Fair
Poor
Have you ever had any serious/difficult problems associated with previous dental work?
Yes
No
Have you ever had any pain or tenderness in the jaw joint?
Yes
No
Have you ever had any trauma to the mouth or jaw joint?
Yes
No
Please describe trauma:
Do you have a mouth breathing habit?
Yes
No
Do you have tooth sensitivity?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do your gums ever bleed?
Yes
No
Types of bristles?
Hard
Medium
Soft
How many times a week do you floss?
How many times a week do you brush?
Do you have a primary care physician?
Yes
No
Name:
Phone:
Current medical health:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Explain:
For Women Only
Are you pregnant?
Yes
No
Weeks:
Are you taking birth control pills?
Yes
No
Are you nursing?
Yes
No
Heart Murmur
Yes
No
Cancer
Yes
No
Diabetes
Yes
No
Rheumatic Fever
Yes
No
HIV+\AIDS
Yes
No
Hemophilia
Yes
No
Asthma
Yes
No
Hepatitis
Yes
No
Heart Attack
Yes
No
Tuberculosis
Yes
No
Kidney/Liver Problems
Yes
No
Shingles
Yes
No
Fever Blisters
Yes
No
Venereal Disease
Yes
No
Ulcers/Colitis
Yes
No
Emphysema
Yes
No
Sinus Problems
Yes
No
Prosthesis
Yes
No
Difficulty Breathing
Yes
No
Whiplash
Yes
No
Major Accidents
Yes
No
Congenital Heart Defect
Yes
No
Convulsions/Epilepsy
Yes
No
Abnormal Breathing
Yes
No
Hearing Impairment
Yes
No
Any Operations
Yes
No
Any stays in the hospital
Yes
No
Handicaps/Disabilities
Yes
No
Allergies to any drugs
Yes
No
History of Scarlet Fever
Yes
No
Artificial Valves
Yes
No
Heart Surgery/Pacemaker
Yes
No
Mitral Valve Prolapse
Yes
No
Artificial Bones/Joints
Yes
No
Frequent Headaches
Yes
No
Hi/Low Blood Pressure
Yes
No
Drug/Alcohol Abuse
Yes
No
Blood Transfusion
Yes
No
Anemia/Radiation Tx
Yes
No
Glaucoma
Yes
No
Osteoporosis
Yes
No
Arthritic Conditions
Yes
No
Other:
Are you allergic to any of the following?
Aspirin
Yes
No
Codeine
Yes
No
Latex
Yes
No
Penicillin
Yes
No
Erythromycin
Yes
No
Tetracycline
Yes
No
Other
Yes
No
Have you been treated with antibiotics prior to a routine dental appointment? If yes please describe:
Are you taking prescriptions drugs?
Yes
No
List:
I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations.
Initials
I consent to the knowledge of video surveillance throughout the premises of Orthodontics LTD. for security purposes.
Initails:
I understand the information that I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in my child's medical status.
Signature of Patient/Guardian:
Date: