Required fields *
ADULT PATIENT INFORMATION
Date
Date of Birth
Age
Sex
Name
Home Phone
Address
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Cell Phone
Carrier
Email
I request appointment reminders via:
Email
Text
Both
None
Your Employer
Business Address
Occupation
Work Phone
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Spouse's Name
Workplace/Occupation
Cell Phone
Referred By
Family Dentist
INSURANCE INFORMATION
Do you have insurance coverage for orthodontic treatment?
Yes
No
Employee Name
ID Number
Birthday
Insurance Company #1
Employer
Group Number
Employee Name
ID Number
Birthday
Insurance Company #2
Employer
Group Number
HEALTH QUESTIONNAIRE
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
Physician Name
Business Address
Phone Number
City
State
Select your option
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Presently under physician's care during the past two years other than routine exams?
Yes
No
If Yes, please specify:
Have you ever taken any oral or I.V. bisphosphonate medications (i.e. Fosamax, Boniva, Actonel, Zometa, Aredia) for the treatment of osteoporosis, bone pain or other conditions?
Yes
No
If Yes, please specify:
Presently taking any medications?
Yes
No
If Yes, please list:
Congenital anomalies (birth defects)?
Yes
No
If Yes, please specify:
Female: Are you pregnant now?
Yes
No
If Yes, due date:
Have you had a history of any of the following?
ASTHMA
SEXUALLY TRANSMITTED DISEASE
INFECTIOUS DISEASE
CARDIOVASCULAR DISEASE
TONSILLITIS
HEPATITIS OR LIVER DISEASE
CANCER
BONE DISORDER
DIABETES
HAY FEVER
EMOTIONAL PROBLEMS
ARTHRITIS OR PAINFUL JOINTS
HEART MURMUR
DIZZINESS
ALCOHOLISM
HERPES
AIDS OR HIV POSITIVE
HEARING DISORDER
SINUS PROBLEMS
EXCESSIVE BLEEDING
MIGRAINE HEADACHES
RHEUMATIC FEVER
CONVULSIONS
DRUG ABUSE
TUMOR OR GROWTH
IMMUNE SYSTEM PROBLEMS
OTHER
RESPIRATORY PROBLEMS
FAINTING
BLOOD DISEASE
EPILEPSY
Other conditions not listed:
Comments:
Have you had any serious illness, operation, or been hospitalized within the past 5 years?
Yes
No
If so, what was the illness or problem?
Respiratory History: Do you:
Have allergies to:
Seasonal Grasses
Yes
No
Foods
Yes
No
If YES, specify:
Medications
Yes
No
If YES, specify:
Other
Yes
No
If YES, specify:
Snore when sleeping?
Seldom
Sometimes
Often
Breathe through mouth?
Seldom
Sometimes
Often
Have frequent colds?
Seldom
Sometimes
Often
Have frequent stuffy nose?
Seldom
Sometimes
Often
Have frequent sore throat or tonsillitis?
Seldom
Sometimes
Often
Have chewing or swallowing difficulty?
Seldom
Sometimes
Often
Have frequent ear infections?
Seldom
Sometimes
Often
Have you recieved medical treatment from an allegist or ear, nose and throat specialist?
Yes
No
If Yes, please specify:
When:
By whom:
For what condition?
Have you had your adenoids removed?
Yes
No
Have you had your tonsils removed?
Yes
No
Have you received or been requested to receive speech correction?
Yes
No
Do you have pain or clicking in the jaw joints?
Yes
No
If Yes, please specify:
Do you have frequent headaches?
Yes
No
If Yes, please specify:
Have any teeth been injured due to accidents or blows to the mouth?
Yes
No
If Yes, please specify:
Please provide information as it pertains to you regarding the following habits:
Thumb sucking until age
Finger sucking until age
Grinding of teeth
Yes
No
Tongue thrusting
Yes
No
Nail biting
Yes
No
Smoking
Yes
No
Lip biting or sucking
Yes
No
Other
Have you had any unusual dental experiences?
Yes
No
If yes, please specify:
Date of last dental cleaning:
Have you had any previous orthodontic consultations?
Yes
No
Or treatment?
Yes
No
Date:
Doctor:
Orthodontic consultation prompted by:
Patient
Dentist
Physician
Spouse
Friend
Other
Your Interest in orthodontic treatment:
Eager
Indifferent
Resigned
Opposed to treatment
What do you feel is the primary problem?
Have any family members been examined or treated in our office?
Yes
No
If Yes, please specify:
AUTHORIZATION
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsiblity to inform this office of any changes in my medical status.
Signature of Patient
Date
Submit