Adult Patient Personal Information
Title:
Dr.
Mr.
Ms.
Mrs.
Miss
*
First Name:
*
Last Name:
Preferred Name:
Male
Female
Other
*
Birthdate is not in correct format (MM/DD/YYYY)
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:
Birthdate is not in correct format (MM/DD/YYYY)
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:
Birthdate is not in correct format (MM/DD/YYYY)
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.