Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Nickname/Preferred Name:
Birthdate:
Gender:
Male
Female
Identifying Gender:
Address:
City:
State:
Zip:
Email:
Phone:
Social Security Number:
How would you like to be contacted?
Email
Phone
Text
How did you hear about us? Check all that apply.
Commercials
Facebook
Dentist
Google
Insurance Company
Invisalign
Mailers
Website
ADK Employee
Patient
Other
If Patient, ADK Employee or Other was selected, please provide details:
Whom may we thank for referring you to our practice?
Are any of your friends and/or family currently in treatment with Adirondack Orthodontics? If yes, please list their names and relation to patient.
No
Yes
Name:
Relationship:
Acquaintance
Father
Friend
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Name:
Relationship:
Acquaintance
Father
Friend
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Name:
Relationship:
Acquaintance
Father
Friend
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Responsible Party Information
Check if the patient is also the person who will be financially responsible for treatment.
Parent/Guardian 1
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone 1:
Phone 2:
Address:
City:
State:
Zip:
Email:
Social Security Number:
Parent/Guardian 2
First Name:
Middle Initial:
Last Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone 1:
Phone 2:
Address:
City:
State:
Zip:
Email:
Social Security Number:
Dental Insurance Information
Primary Insurance
Policy Holder Name:
Policy Holder Date of Birth:
Insurance Company:
Subscriber ID:
Group #:
Claims Address:
Relations to Patient:
Secondary Insurance
Policy Holder Name:
Policy Holder Date of Birth:
Insurance Company:
Subscriber ID:
Group #:
Claims Address:
Relations to Patient:
Emergency Contact Information
Emergency Contact 1
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Emergency Contact 2
Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Phone:
Dental History
Dentist Name:
Last Dental Visit:
Frequency of Dental Visits?:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
Dental Hygiene:
How frequently do you...
Brush?
Floss?
Fluoride Treatment?
*
No
Yes
Have you ever had a consultation/received orthodontic treatment? If yes, please explain for what and when.
No
Yes
Do you have a condition that requires
pre-medication
prior to the start of treatment?
No
Yes
Have wisdom teeth been removed?
Please check all/any conditions that apply to you:
Speech Problems/Therapy
Grind or Clench Teeth
Oral Habits (thumb/finger habit, lip/nail biting)
Injury to jaw, teeth, or mouth
Discomfort from teeth or gums
Frequent headaches
Pain, tenderness, or noise in either jaw
Neck/Shoulder pain
Frequent sore throats
Chipped or injured permanent teeth
Teeth sensitivity to cold or hot
Previous root canal therapy
Bad taste/mouth odor
Previous Periodontal (gum) treatment
Abnormal swallowing (tongue thrust)
Teeth that irritate tongue, cheek, lip, etc.
Numerous fillings
Mouth breathing
Snores during sleep
Any missing or extra permanent teeth
Apprehensive about dental care
Frequently chews gum
Thumb/Finger habit as a child
Jaw fractures, cysts, mouth infections
Bleeding gums
Other periodontal (gum) problems
Frequent canker sores or cold sores
Problems with food trapped between teeth
If you answered yes
to any of the items listed above, please explain each selection. This provides our clinicians with all the information needed to provide you with the best treatment and care possible.
Are you experiencing any other dental conditions that were not listed above?
Please check all/any conditions that apply to you:
Had a TMJ screening
Experience soreness in the muscles of face or around ears
History of jaw joint problems
Notice clicking or popping in jaw joint
Have you ever been treated for "TMJ"?
Do you clench your teeth
Does/Has your jaw ever locked?
Difficulty chewing or opening mouth
Does bite feel uncomfortable or unusual?
If you answered yes
to any of the items listed above, please explain each selection. This provides our clinicians with all the information needed to provide you with the best treatment and care possible.
Medical Questionnaire
*
No
Yes
Is the patient under care of a physician? If yes, physician's name:
*
No
Yes
Any changes in the patient's general health within the last year?
If yes:
*
No
Yes
Has the patient had a serious illness or hospitalization in the past 5 years?
If yes:
*
No
Yes
Does the patient have an intellectual, cognitive, or developmental disability?
If yes:
*
No
Yes
Are you currently taking any medications or blood thinners? If yes, please indicate each medication.
Drug Allergies/Sensitivities
Please check any/all that apply to the patient
Latex
Sulfa Drugs
Metal Allergy
Penicillin or other antibiotics
Local Anesthetics
Codeine or other narcotics
Aspirin, Ibuprofen, Tylenol
Other
If you answered X
to any of the items listed above, please explain each selection. This provides our clinicians with all the information needed to provide you with the best treatment and care possible.
Medical History
Please check any/all that apply to the patient
Diabetes
Growth problems
Tuberculosis/Lung disease
Pneumonia
Arteriosclerosis
Thyroid/Endocrine problems
Stomach ulcer or hyperacidity
Hypertension/High blood pressure
Asthma
Anemia/Blood disorder
HIV/AIDS
Tonsils/Adenoids removed
Arthritis/Joint problems
Bone disorder/Bone loss
Seizures/Epilepsy
Neurological Disease
Cancer
Family history of cancer
Radiation Treatment
Prolonged Bleeding/Transfusion
Respiratory problems/Emphysema
Taking Bisphosphonates (Fosamax, Boniva)
Bone Fractures/Trauma to face jaw
Other:Any medical condition not listed
Female patients only: Are you pregnant?
If you answered X
to any of the items listed above, please explain each selection. This provides our clinicians with all the information needed to provide you with the best treatment and care possible.
Are there any other conditions that you would like our clinical staff to know?
Patient Motivation For Orthodontic Treatment
What would you like to change most in the appearance of your teeth and/or facial appearance?
Are you experiencing any pain or discomfort in your gums, teeth, or jaw?
*
No
Yes
Is there anything we can do as a practice to ensure the patient has a positive experience?
If yes:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.
Signature:
Date:
Relationship to Patient: