Adult Patient Form

Adult Patient Form
Patient Name*
Nickname
Gender*

MaleFemaleNon-binaryN/A
Gender at Birth*

MaleFemale
Birthdate*

MonthDayYear
Date
Age
Height
Weight
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we thank for referring you to our office?
Please list your chief complaint/concern:
Responsible Party Information
Occupation*
Employed By*
Email (if different)
example@example.com
Cell Phone (if different)

Area CodePhone Number
Spouse Name
Spouse Date of Birth

MonthDayYear
Date
Spouse Occupation
Spouse Employed By
Spouse Email
example@example.com
Spouse Cell Phone

Area CodePhone Number
Where/Whom to call in case of Emergency?*
Dental Insurance Information
Do you have dental insurance?*

YesNo
Primary Insured's Name
Primary Insured's SSN
Primary Insured's DOB

MonthDayYear
Date
Primary Insurance Company
Primary Insurance Co. Phone

Area CodePhone Number
Primary Insurance Policy Number
Primary Insurance Group Number
Secondary Insured's Name
Secondary Insured's SSN
Secondary Insured's DOB

MonthDayYear
Date
Secondary Insurance Company
Secondary Insurance Co. Phone

Area CodePhone Number
Secondary Insurance Policy Number
Secondary Insurance Group Number
Medical Information
Your Physician
Physician Phone

Area CodePhone Number
Are you in good health?*

YesNo
History of major illness or conditions?*

YesNo
I require antibiotic premedication for dental appointments?*

YesNo
Please check any of the following that you have had or currently have and add relevant comments below:

*DK/U: Don't know/understand
Allergies*

YesNoDK/U
Asthma, sinus problems, hay fever*

YesNoDK/U
Anemia, excessive bleeding or bruising*

YesNoDK/U
Any injuries to face, head or neck*

YesNoDK/U
Arthritis or joint problems*

YesNoDK/U
Birth defects or hereditary problems*

YesNoDK/U
Bone disorders, fractures or major injuries*

YesNoDK/U
Cancer, tumor, radiation or chemotherapy*

YesNoDK/U
Cardiovascular disease, heart defects*

YesNoDK/U
Chest pain, shortness of breath*

YesNoDK/U
Diabetes or low blood sugar*

YesNoDK/U
Emotional problems*

YesNoDK/U
Endocrine or thyroid problems*

YesNoDK/U
Epilepsy or convulsion*

YesNoDK/U
Fever blisters/herpes*

YesNoDK/U
Frequent ear or throat infections, colds*

YesNoDK/U
Frequent headaches or migraines*

YesNoDK/U
High or low blood pressure*

YesNoDK/U
History of osteoporosis*

YesNoDK/U
HIV - AIDS*

YesNoDK/U
Hypoglycemia*

YesNoDK/U
Immune system disorders*

YesNoDK/U
Kidney problems*

YesNoDK/U
Mental health disturbance or depression*

YesNoDK/U
Rheumatic fever*

YesNoDK/U
Seizures, fainting, neurologic problems*

YesNoDK/U
Polio, mononucleosis, TB, pneumonia*

YesNoDK/U
Sexually transmitted infections*

YesNoDK/U
Skin disorder (other than common acne)*

YesNoDK/U
Ulcers/GERD/Reflux*

YesNoDK/U
You tire easily upon exertion*

YesNoDK/U
Please list all present medications*
Have tonsils or adenoids been removed?*

YesNo
Have you been diagnosed with sleep apnea?*

YesNo
Do you use CPAP?*

YesNo
Do you use tobacco products?*

YesNo
Please list any implanted medical device
(Females) Do you take bisphosphonates?

YesNo
(Females) Are you pregnant?

YesNo
Please describe any other medical conditions that you have, not listed above.*
Dental Information
Name of General Dentist*
Have you had a recent dental exam?*

YesNoDK/U
Do you have regular cleanings?*

YesNoDK/U
Injuries to mouth or teeth?*

YesNoDK/U
Previous orthodontic treatment?*

YesNoDK/U
Adult teeth removed for braces?*

YesNoDK/U
Have non-restorable teeth been extracted?*

YesNoDK/U
Have wisdom teeth been extracted?*

YesNoDK/U
Have you had any root canals?*

YesNoDK/U
Do you have any bridges?*

YesNoDK/U
Do you have any dental implants?*

YesNoDK/U
Any sensitive or sore teeth?*

YesNoDK/U
Bleeding gums, bad taste or mouth odor?*

YesNoDK/U
Jaw fractures, cysts or infections?*

YesNoDK/U
Has jaw ever locked open or closed?*

YesNoDK/U
Have you had treatment specific for TMJ?*

YesNoDK/U
Clicking in jaw joints?*

YesNoDK/U
Soreness in jaw or facial muscles?*

YesNoDK/U
Difficulty eating or chewing?*

YesNoDK/U
Food impaction between the teeth?*

YesNoDK/U
Abnormal swallowing (tongue thrust)?*

YesNoDK/U
Teeth grinding or clenching?*

YesNoDK/U
Do you wear a nightguard?*

YesNoDK/U
Difficulty breathing through nose?*

YesNoDK/U
Are you a mouth breather?*

YesNoDK/U
History of speech problems?*

YesNoDK/U
Have you had any jaw surgery?*

YesNoDK/U
Any teeth irritating lips, cheeks or gums?*

YesNoDK/U
Frequent mouth sores or herpes sores?*

YesNoDK/U
I chew on my nails, pens or other objects.*

YesNoDK/U
Any broken or missing fillings?*

YesNoDK/U
High intake of sweets or sodas?*

YesNoDK/U
Any diagnosis of gum disease?*

YesNoDK/U
Any traumatic past dental experience?*

YesNoDK/U
List sports played
Hobbies/Interests
Your attitude toward orthodontics

EagerComplacentNot Enthusiastic
We welcome your comments and suggestions.
Acknowledgement of Receipt of Notice of Privacy Practices
Signature
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Adult Patient Form

Responsible Party Information

Dental Insurance Information

Medical Information

Dental Information

Acknowledgement of Receipt of Notice of Privacy Practices

Signature