Adult Patient Personal Information
Title:
Dr.
Mr.
Ms.
Mrs.
Miss
First Name:
Last Name:
Preferred Name:
Male
Female
Other
Birthdate:
Address:
City:
Province:
Postal Code:
Home Phone:
Work Phone:
Cell Phone:
Email:
Occupation:
Marital Status:
Single
Common Law
Married
Separated
Divorced
Widowed
Person responsible for financial obligation:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Additional person responsible for financial obligation:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Dental History
Family Dentist:
Date of last dental check-up:
Dental Clinic Name:
Clinic Phone Number:
Have you seen an Orthodontist before?
No
Yes
If yes, when?
If yes, who and where?
Have you ever required antibiotics or other medications prior to dental treatment?
No
Yes
If yes, please explain:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Jaw joint problems?
No
Yes
Grinding and/or clenching of teeth?
No
Yes
Thumb/finger sucking?
No
Yes
Injury to face or teeth?
No
Yes
Tongue position or swallowing problems?
No
Yes
Tonsils or adenoids removed?
No
Yes
Speech/articulation problems?
No
Yes
Any difficulty chewing?
No
Yes
Any difficulty with speech?
No
Yes
Mouth breathing more than nose breathing?
No
Yes
Medical History
Family Physician:
Date of last medical check-up:
Are you currently under medical care?
No
Yes
If yes, please explain:
Please list any allergies you have:
Please list any medications being taken:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Nickel/Metal allergy?
No
Yes
Latex allergy?
No
Yes
Rheumatic fever?
No
Yes
Epilepsy or Seizures?
No
Yes
Hereditary problems?
No
Yes
Asthma?
No
Yes
Headaches?
No
Yes
Hepatitis?
No
Yes
Heart murmur?
No
Yes
Heart problems?
No
Yes
H.I.V. positive?
No
Yes
Diabetes?
No
Yes
Anemia?
No
Yes
Prolonged bleeding?
No
Yes
Snoring or Sleep Apnea?
No
Yes
Please list any other conditions or treatments pertaining to your health that we should be aware of:
Dental Insurance Information
Policy Subscriber's Full Name:
Employer/Company Name:
Insurance Company:
Group/Policy Number:
Certificate or I.D. Number:
Subscriber's Date of Birth:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Subscriber's Full Name:
Employer/Company Name:
Insurance Company:
Group/Policy Number:
Certificate or I.D. Number:
Subscriber's Date of Birth:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Whom may we thank for referring you to our practice?
Reason for today's visit:
I consent to having Dr. Boutin do a clinical orthodontic examination and photographic documentation.
I consent to the discretionary and anonymous use of my clinical photos and x-rays for Dr. Boutin's educational/teaching purposes.