Patient Information- Adult

First Name:
MI:
Last Name:
Preferred Name:
Gender:
Date of Birth:
Home Phone:
Work Phone:
Cell Phone:
Address:
City:
State:
Zip:
Email:
Employer:
Marital Status:
Current General Dentist:
How long since the last dental visit?
How did you hear about our office?
What are your primary goals for orthodontic treatment?
Is this your first visit to an orthodontist?
Have we treated a family member or friend?
If yes, Name(s):
Is there anything that you would like to discuss with Drs. Littlefield or Lovell in private?

Insurance Information

If you have an insurance card we would be happy to make a copy and enter this information for you at your visit.
Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy #:
Do you have secondary coverage?
Insured's Name:
Insured's Employer:
Insured's Social Security #:
Insured's Date of Birth:
Insurance Company:
Insurance Company Phone:
Insurance Company Address:
Group #:
Policy #:

Medical History

Last Physical Date:
Has there been any change in the patient's general health within the last year?
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?   
List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:
Latex
Penicillin or other antibiotics
Sulfa drugs
Aspirin, Ibuprofen, Tylenol
Local anesthetics
Codeine or other narcotics
Other:
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Heart Murmur
Damaged or artificial heart valves
Congenital Heart Defect
Heart Disease
Rheumatic Fever
Angina
Liver Disease/Jaundice/Hepatitis
Kidney Disease
Heart Attack/Stroke
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia/Blood disorder
HIV/AIDS
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis/Joint problems
Large Tonsils
Sinus trouble
Bed wetting
Substance abuse problem (past or present)
Bone fractures/trauma to face/jaw
Prosthetic joints
Chronic fatigue
Diabetes
Growth Problems
Tuberculosis or Lung Disease
Pneumonia
Cancer
Family History of Cancer
Received Radiation Treatment
Arteriosclerosis
Thyroid/Endocrine Problems
Stomach ulcer or hyperacidity
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures/Epilepsy/Neurological Disease
Treated for Emotional Problems
Asthma
Respiratory problems/Emphysema
Persistent swollen neck glands
Sexually transmitted disease
Low blood pressure
Persistent cough
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:

Dental History

Chipped or injured permanent teeth?
Teeth sensitive to hot or cold?
Previous root canal therapy?
Bad taste/mouth odor?
Previous orthodontic treatment or retainer?
Damaged restorations/fillings?
Loose or shifting teeth?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Teeth that irritate tongue, cheek, lip, etc?
Numerous fillings?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
Thumb or finger habit as a child?
Jaw Fractures, cysts, mouth infections?
Bleeding gums?
Other periodontal (gum) problems?
Frequent canker sores or cold sores?
Have wisdom teeth been removed?
Problems with food trapped between teeth?
Is there any dental work yet to be completed?
If any of the above dental questions were answered 'Yes', please explain:
Have you had a TMJ screening?
Do you have pain in your jaw joint?
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"?
Do you notice clicking or popping in your jaw joint?
Do you grind your teeth?
Do you clench your teeth?
Has your jaw ever locked?
Do you have difficulty chewing or opening your mouth?
Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
Symptoms - If you want to reduce pain or discomfort, please be specific about its location; check the right or left side or both if they apply.

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?
Face - If your facial appearance could be changed, what would you change?

By checking the boxes and signing below, I am giving my consent to Littlefield & Lovell Orthodontics regarding the following:

Signature:
Date: