• Adult Patient Form

    Adult Patient Form

  • Gender*
  • Gender at Birth*
  • Birthdate*
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  • Responsible Party Information

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  • Spouse Date of Birth
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  • Dental Insurance Information

  • Do you have dental insurance?*
  • Primary Insured's DOB
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  • Secondary Insured's DOB
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  • Medical Information

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  • Are you in good health?*
  • History of major illness or conditions?*
  • I require antibiotic premedication for dental appointments?*

  • 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*
  • Asthma, sinus problems, hay fever*
  • Anemia, excessive bleeding or bruising*
  • Any injuries to face, head or neck*
  • Arthritis or joint problems*
  • Birth defects or hereditary problems*
  • Bone disorders, fractures or major injuries*
  • Cancer, tumor, radiation or chemotherapy*
  • Cardiovascular disease, heart defects*
  • Chest pain, shortness of breath*
  • Diabetes or low blood sugar*
  • Emotional problems*
  • Endocrine or thyroid problems*
  • Epilepsy or convulsion*
  • Fever blisters/herpes*
  • Frequent ear or throat infections, colds*
  • Frequent headaches or migraines*
  • High or low blood pressure*
  • History of osteoporosis*
  • HIV - AIDS*
  • Hypoglycemia*
  • Immune system disorders*
  • Kidney problems*
  • Mental health disturbance or depression*
  • Rheumatic fever*
  • Seizures, fainting, neurologic problems*
  • Polio, mononucleosis, TB, pneumonia*
  • Sexually transmitted infections*
  • Skin disorder (other than common acne)*
  • Ulcers/GERD/Reflux*
  • You tire easily upon exertion*
  • Have tonsils or adenoids been removed?*
  • Have you been diagnosed with sleep apnea?*
  • Do you use CPAP?*
  • Do you use tobacco products?*
  • (Females) Do you take bisphosphonates?
  • (Females) Are you pregnant?

  • Dental Information

  • Have you had a recent dental exam?*
  • Do you have regular cleanings?*
  • Injuries to mouth or teeth?*
  • Previous orthodontic treatment?*
  • Adult teeth removed for braces?*
  • Have non-restorable teeth been extracted?*
  • Have wisdom teeth been extracted?*
  • Have you had any root canals?*
  • Do you have any bridges?*
  • Do you have any dental implants?*
  • Any sensitive or sore teeth?*
  • Bleeding gums, bad taste or mouth odor?*
  • Jaw fractures, cysts or infections?*
  • Has jaw ever locked open or closed?*
  • Have you had treatment specific for TMJ?*
  • Clicking in jaw joints?*
  • Soreness in jaw or facial muscles?*
  • Difficulty eating or chewing?*
  • Food impaction between the teeth?*
  • Abnormal swallowing (tongue thrust)?*
  • Teeth grinding or clenching?*
  • Do you wear a nightguard?*
  • Difficulty breathing through nose?*
  • Are you a mouth breather?*
  • History of speech problems?*
  • Have you had any jaw surgery?*
  • Any teeth irritating lips, cheeks or gums?*
  • Frequent mouth sores or herpes sores?*
  • I chew on my nails, pens or other objects.*
  • Any broken or missing fillings?*
  • High intake of sweets or sodas?*
  • Any diagnosis of gum disease?*
  • Any traumatic past dental experience?*
  • Your attitude toward orthodontics

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • Signature

  • Date*
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  • Should be Empty: