Adult Patient Information

  Patient Biographical Information    
Title:  
*First Name:  
Middle Initial:
*Last Name:  
Age
*Birthdate:    
Social Security #:
Email:
*Home Address:  
*City:  
*State:  
*Zip:  
*Home Phone:  
Would you object to an automated telephone call to remind you of an upcoming appointment?
Employer:
Address:
City:
State:
Zip:
Business Phone #:  
Occupation:  
Insurance:  
Marital Status:
Spouse's Name:
Employer:
Address:
City:
State:
Zip:
Social Security #:  
Business Phone #:  
Occupation:  
Insurance:  
  Responsible Party Information (credit bureau reports, where appropriate may be obtained)    
*First Name:  
*Last Name:  
*Address:  
*City:  
*State:  
*Zip:  
  Dental/Medical History     
Physician Name:
Dentist Name:
Dentist Since:
Have you completed all recommended dental work?
Date of last Physical:  
Last Dental Visit:  
Do you see your dentist on a regular basis?
How did you come to choose our office? (indicate as many as applicable)
Dentist Referral?
Insurance Plan Referral?
Location?
Other family members treated at this office?
Recommendations of neighbors and friends?
Other? (physician, Yellow Pages, dental society, Google, invisalign, etc.)
   
   
   
Names:  
Names:  
Explain:  
Have you ever had an orthodontic evaluation or orthodontic diagnostic records taken?   
  Have you ever had previous orthodontic treatment or worn a "retainer" or "biteplate"?
When?  
  Have you been treated for periodontal (gum) disease?
When?  
Explain:  
By? (Dentist, Orthodontist):  
Explain:  
By? (Dentist, Periodontist)  
What is your primary concern (why are you here?)
Please select YES if the patient has had any of the conditions listed below either now or in the past.
  Require antibiotic premedication for dental work
  Do you have a current medical problem?
  Heart Trouble, Congenital Heart Defect, Rheumatic Fever
  High/Low Blood Pressure
  Diabetes
  Fainting/Dizziness
  Epilepsy
  Headaches
  Psychological/Nervous Disorders
  Allergic to Latex (gloves), Metals, or medications?
  Gland or Blood Disorders, Kidney Disease, Anemia
  Asthma/Hay Fever/Severe Allergies
  Infectious Hepatitis/Jaundice/Tuberculosis
  Major Operations/Cancer/Tumors
  Radiation Treatment to Head Area
  Taking Medication
  Use Tobacco
  Sexually Transmitted Disease
  HIV Positive
  Perspire Excessively, Persistent Diarrhea, Purplish Rash, Persistent Bruise
  Prolonged Coughing or Coughing Up Blood
  Lost Weight without Dieting
Dental History
  Growth/Swelling/Sores in Mouth
  Mouth Sensitive to Temperature/Pressure/Food/Drink
  Pain or Soreness around Eyes, Ears or Face
  Bleeding or Swollen Gums
  Stiff Neck Muscles
  Awaken with Awareness of Teeth or Jaws
  Clench Teeth During Daytime
  Grind Teeth in Sleep
  Jaw Clicking or Popping while Eating or Yawning
  Difficulty Opening Mouth Widely
  Jaw Ever Locked Open or Closed
  Interested in Bleaching Teeth
For Women  
Pregnant
Hormonal Therapy or Treated for Potential Osteoporosis
Explain  
Explain:  
Explain:  
Controlled:  
Controlled:  
When:  
Medication:  
How often:  
Controlled:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
List:  
How much:  
Explain:  
Explain:  
Explain:  
Explain:  
How Much:  
For How Long:  
Explain:  
Explain:  
Explain:  
How Often:  
How Often:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
Explain:  
   
Expected Due Date:  
Explain:  
Please amplify answers if necessary: