Adult Patient Information Form

Adult Patient Information Form
PATIENT INFORMATION
Whom may we thank for referring you to our office?
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Birth Date

MonthDayYear
Date
Sex
Identifies As
Occupation
SSN
Reason for Visit:
Spouse's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Occupation
SSN
INSURANCE INFORMATION
Insured's Name

First NameLast Name
Insurance Company
Member ID # / Subscriber #
Group #
DOB of Subscriber

MonthDayYear
Date
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Do you have dual coverage?

YesNo
Insured's Name

First NameLast Name
Insurance Company
Subscriber #
Group #
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Please enter a valid phone number.Format: (000) 000-0000.
GENERAL INFORMATION
Number of Children in Family:
Name(s) of any family member(s) in treatment or previously with us:
Name of Previous Orthodontist:
General Dentist's Name
General Dentist's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Dental Check-Up

MonthDayYear
Date
Is the patient currently under treatment?

YesNo
Physician's Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Check-Up

MonthDayYear
Date
Is the patient currently under treatment?

YesNo
ANY HISTORY OF:
Thumb or finger sucking?

YesNo
If yes, until what age?
Grinding of teeth?

YesNo
If yes, when?
Frequent headaches or jaw pain?

YesNo
Difficulty eating any foods?

YesNo
Speech difficulty or speech therapy?

YesNo
MEDICAL HISTORY
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.
Are you in general good health at this time?

YesNo
Are you under any medical treatment now?

YesNo
Are you taking any drugs or medications?

YesNo
If yes, please list:
Have you ever had any adverse response to any drugs, including penicillin?

YesNo
If yes, please list:
Is the patient allergic to any known materials/foods resulting in hives, asthma, eczema, or anaphylaxis?

YesNo
If yes, please list:
Has the patient ever had any major operations including hip/joint replacement?

YesNo
If yes, please specify:
Are you allergic to latex?

YesNo
Have you ever had any radiation therapy or chemotherapy?

YesNo
Have you ever had a serious accident involving head injuries?

YesNo
Have you had a history of any of the following?

AsthmaHeart MurmurTumor or GrowthTonsillitisAIDS or HIV PositiveFaintingDiabetesMigraine HeadachesCardiovascular DiseaseCancerHay FeverHerpesSinus ProblemsRheumatic FeverRespiratory ProblemsBlood DiseaseSexually Transmitted DiseaseBone DisorderEmotional ProblemsDizzinessExcessive BleedingConvulsionsImmune System ProblemsEpilepsyInfectious DiseaseHepatitis or Liver DiseaseArthritis or Painful JointsAlcoholismHearing DisorderDrug AbuseOther
Do you snore?

YesNo
Do you have a history of fainting?

YesNo
Are you pregnant?

YesNo
DENTAL HISTORY
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.
Have you ever had gum disease, or periodontal treatment?

YesNo
Do you frequently get sore spots in your mouth?

YesNo
Do you have any dental complaints at the present time?

YesNo
Do you experience frequent headaches?

YesNo
Do you have any clicking or popping of your jaw (TMJ)?

YesNo
Do you have pain in or around your ears?

YesNo
Do you chew on only one side of your mouth?

YesNo
If so, why?
Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc.)?

YesNo
If so, where?
Have you ever taken any appetite suppressants (Fen-Phan, Dexfenfluramine, Fenfluramine, or other)?

YesNo
PATIENT MEDICAL/DENTAL HISTORY
In case of an emergency, contact:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
PURPOSE OF CONSENT (HIPAA)
By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.
Signature of Patient
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Information Form

PATIENT INFORMATION

INSURANCE INFORMATION

GENERAL INFORMATION

ANY HISTORY OF:

MEDICAL HISTORY

DENTAL HISTORY

PATIENT MEDICAL/DENTAL HISTORY

PURPOSE OF CONSENT (HIPAA)