Bond Orthodontics Adult Patient Form

Date

MonthDayYear
Date
Patient's Name

First NameMiddle NameLast Name
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Cell Phone
Home Phone
Please enter a valid phone number.
Work phone
Previous Address (If less than 3 years)
Birthdate

MonthDayYear
Date
Social Security #
Email Address
example@example.com
Marital Status

SingleMarriedSeparatedDivorced/Widowed
Employer
Occupation
Number of Years Employed at Current Employer
Spouse's Information

(If Applicable)
Spouse's Name
Relationship to Patient
Employer
Occupation
Number of Years at Current Employer
Social Security #
Birthdate

MonthDayYear
Date
Best Phone Number
Whom may we thank for referring you to our office?
Please list names and date of birth of any children:
Dental Insurance Information
Insured's Name
Insured's Social Security #
Insurance Company
Group No.
Local No.
Insurance Co. Address
Phone No.
Do you have Dual Coverage? (If yes, fill out below)

Yes (fill out section below)No
Insured's Name
Insured's Social Security #
Insurance Company
Phone No.
Group No.
Local No.
Insurance Co. Address
Emergency Contact Information
Name of nearest relative not living with you
Address: Street
City
Zip
Phone
I understand that, where appropriate, credit bureau reports may be obtained.
Signature

Clear
Updates (date & initial)

MonthDayYear
Date
Initials
MEDICAL HISTORY
Physician's Name
Date of Last Visit

MonthDayYear
Date
Address
Phone
Please Check Yes or No for each question below: (If Yes, please fill in details)
Are you taking any medication?

NoYes, Explain Below:
Are you allergic to any medication?

NoYes, explain below:
Do you have a history of a major illness?*

NoYes, explain below:
Have you had any operations?*

NoYes, explain below:
Have you ever been involved in a serious accident?*

NoYes, explain below:
Have you ever smoked or chewed tobacco?*

NoYes, how many years?
Have seen a physician in the last 12 months?*

NoYes, for what reason?
Female Patients only:
Are you pregnant?

YesNo
Has menstruation started?

YesNo
Please check any medical conditions below that you have had or currently have

Abnormal bleeding/HemophiliaDiabetesAnemiaDizzinessHepatitis/Liver ProblemsPneumoniaHerpesProlonged BleedingArthritisEpilepsyHigh Blood PressureRadiation/ChemotherapyAsthma or HayfeverGastrointestinal DisordersHIV / AidsRheumatic FeverBone DisordersHeart ProblemsKidney ProblemsTuberculosisCongenital Heart DefectHeart MurmurNervous DisordersTumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?
DENTAL HISTORY
General Dentist
Date of last visit

MonthDayYear
Date
What concerns you most about your teeth?
Are you presently in any dental pain? Have you ever experienced any unfavorable reaction to dentistry? Have your wisdom teeth been removed? Have you ever lost or chipped any teeth? Have there been any injuries to face, mouth, or teeth? Is any part of your mouth sensitive to temperature? Where? Is any part of your mouth sensitive to pressure? Where? Do your gums bleed when you brush? Do you have any type of thumb or tongue habit? Are you a mouth breather? Have you ever seen an orthodontist? If yes, who and when? What is your attitude toward receiving orthodontic treatment? Has anyone in your family received orthodontic treatment? How did they feel about the result? Do your teeth or jaws ever feel uncomfortable when you awake in the morning? Are you aware of your jaw clicking or popping? Are you aware of clenching your teeth during the day? Have you ever been told that you grind your teeth? Do you have "tension" headaches? Have you ever experienced chronic ringing in your ears? Are you aware that some appointments will be during work hours?
Are you presently in any dental pain?*

NoYes, explain below:
Have you ever experienced any unfavorable reaction to dentistry?*

NoYes, explain below:
Have your wisdom teeth been removed?*

NoYes, what year?
Have you ever lost or chipped any teeth?*

NoYes, explain below:
Have there been any injuries to face, mouth, or teeth?*

NoYes, explain below:
Is any part of your mouth sensitive to pressure?*

NoYes, explain where below:
Is any part of your mouth sensitive to temperature?*

NoYes, explain where below:
Do your gums bleed when you brush?*

NoYes, explain where below:
Do you have any type of thumb or tongue habit?*

NoYes, explain below:
Are you a mouth breather?*

YesNo
Have you ever seen an orthodontist?*

NoYes, who and when below:
What is your attitude toward receiving orthodontic treatment*

PositiveNegative, explain below:
Has anyone in your family received orthodontic treatment?*

NoYes, explain how they felt about the result:
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?*

NoYes, explain below:
Have you ever been told that you grind your teeth?*

NoYes, explain below:
Are you aware of your jaw clicking or popping?*

NoYes, explain below:
Are you aware of clenching your teeth during the day?*

NoYes, please explain:
Do you have tension headaches?*

NoYes, explain below
Have you ever experienced chronic ringing in your ears?*

NoYes, explain below:
Are you aware that some appointments will be during work hours?

YesNo
BENEFITS
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Bond to perform a complete orthodontic evaluation.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Spouse's Information

Dental Insurance Information

Emergency Contact Information

MEDICAL HISTORY

DENTAL HISTORY

BENEFITS