Adult Patient Form

Adult Patient Form
Adult Patient Information
Patient's Name*

First NameLast Name
Email*
example@example.com
Gender
Marital Status
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Responsible Party Name
Responsible Party Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referred By:
Dentist's Name
Dentist Phone Number
Please enter a valid phone number.
Responsible Party Employer
Occupation
Emergency Contact
Relationship
Phone Number
Please enter a valid phone number.
Patient Orthodontic Insurance Information
Are you covered by an Orthodontic Insurance Plan?

YesNo
Subscriber Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Insurance Company
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Subscriber ID #
Group #
Health Information
Name of Medical Doctor
Phone Number
Please enter a valid phone number.
Is the patient in good health?

YesNo
Do you have any history of major illness?

YesNo

During the past two years:

	Yes	No
Have you ever been hospitalized?
Have you been under the care of a physician?

If so, please explain:
Is the patient under the care of a physician?

YesNo
If so, please explain:
Check any of the following which you have had or have at the present:

DiabetesPneumonia/TBHeart TroubleRheumatic FeverBone DisorderHIV/AIDSAnemiaAsthmaEpilepsyUlcersBlood TransfusionAllergies/HivesKidney/Liver DiseaseHigh Blood PressureHepatitis/JaundiceSinus ProblemsBlood DisorderEndocrine ProblemProlonged BleedingFainting/DizzinessRespiratory ProblemNervous DisorderVenereal DiseaseCongenital Heart LesionStomach/Intestinal ProblemHigh Blood Pressure
Does you have any disease, condition, or health problem not listed above?

YesNo
Please list any drug/medications you are currently taking:
Please list any allergies or drug sensitivities you may have:
Have you ever had any X-ray treatment (other than diagnostic)?

YesNo
Women: Are you pregnant?

YesNo
Do you anticipate becoming pregnant?

YesNo
Have you ever had periodontal disease?

YesNo
Do your gums bleed?

YesNo
Do your teeth feel loose?

YesNo
Do you grind/clench your teeth or jaws during the day or night?

YesNo
Do you have sore or sensitive teeth?

YesNo
Do you have pain elsewhere in your face or jaws?

YesNo
Do you experience clicking in the jaw joint?

YesNo
Have there been any injuries to the face, mouth, or teeth?

YesNo
Did you ever suck a thumb/finger?

YesNo
If so, until what age?
Have you been informed of any missing or extra permanent teeth?

YesNo
Has an orthodontist previously been consulted?

YesNo
Has either parent had orthodontic treatment?

YesNo
Please check the reason for today's visit:

CrowdingSpacingMissing TeethOverbiteTiming for TreatmentOther
I have received a copy of this office's Notice of Privacy Policy and consent to the use and disclosure of health information for treatment, payment, and health care operation purposes.
Patient's Signature

Clear
Date

MonthDayYear
Date
Practice Witness
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Form

Adult Patient Information

Patient Orthodontic Insurance Information

Health Information