Adult Intake Form

PLEASE COMPLETE THE FOLLOWING
TODAYS DATE
Last Name*
First Name*
Middle Name
Date of Birth *

MonthDayYear
Age Years Months
Gender at birth*
Gender preference
Street*
City and Province*
Postal Code*
Telephone*
Email Address*
example@example.com
What is your preferred method of contact*

EmailPhoneText
Dentist/Dental office
Dentist telephone number
Please enter a valid phone number.
Who can we thank for your referral?
INSURANCE INFORMATION

PLEASE COMPLETE ALL THAT APPLIES
PLAN 1
Plan Name
Policy ID/Certificate #'s
Coverage for Orthodontics
Plan 1 policy holder date of birth

MonthDayYear
Date
PLAN 2
Plan Name
Policy ID/Certificate #'s
Coverage for Orthodontics
Policy holder 2 date of birth

MonthDayYear
Date
Employers Name
Business Phone
Occupation
EMERGENCY CONTACT
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship
IF YOU ARE CURRENTLY UNDER ORTHODONTIC CARE

COMPLETE THE FOLLOWING
Name of Orthodontist
Address
Province/State:
Date of last visit

MonthDayYear
Date
Date braces removed or to be removed

MonthDayYear
Date
Remarks:
MEDICAL HISTORY

Please complete
Are you in good health?*

YesNo
If NO, please give reason(s):
Any major or unusual illnesses?*

YesNo
If YES, please explain:
Currently under physician's care?*

YesNo
If YES, please give reason(s):
Currently taking medications/supplements?*

YesNo
If YES, please list and/or reason(s):
Allergies:*

YesNo
If YES, please list:
Drug sensitivities?*

YesNo
if YES, please list:
Name of family Physician

First NameLast Name
Phone Number
Please enter a valid phone number.
Anemia*

YesNo
Blood Disease*

YesNo
Prolonged Bleeding*

YesNo
Hepatitis*

YesNo
HIV/AIDS*

YesNo
Jaundice*

YesNo
Rheumatic Fever*

YesNo
Heart Disease*

YesNo
Tuberculosis*

YesNo
Diabetes*

YesNo
Endocrine Problems*

YesNo
Bone Disorders - including osteoporosis*

YesNo
Epilepsy*

YesNo
Herpes - including cold sores*

YesNo
Learning disorders*

YesNo
ADHA/ADD*

YesNo
Frequent colds*

YesNo
Tonsillitis*

YesNo
Adenitis*

YesNo
Tonsils Removed*

NoYes, at age
Adenoids Removed*

NoYes, at age
Asthma*

YesNo
Mouth Breathing*

YesNo
Mouth Breathing

While awakeWhile asleep
Dental History
Have you had any severe head or face injuries?*

YesNo
Please describe
Have you had any previous dental trauma?*

YesNo
If yes, which teeth?
Do you have a history of thumbsucking or fingersucking*

YesNo
What age did you stop?
Do you play any musical (wind) instruments?*

YesNo
What instrument(s)?
Has orthodontic treatment been recommended before?*

YesNo
What has been recommended?
Have you had previous orthodontic treatment?*

YesNo
Please describe your previous orthodontic treatment ?
Do you have or have had any of the following?
History of clenching?*

YesNo
History of grinding?*

YesNo
History of headaches(more than normal)?*

YesNo
Muscular soreness around head and neck?*

YesNo
History of joint soreness?*

YesNo
History of jaw joint clicking?*

YesNo
History of jaw joint popping?*

YesNo
History of ringing in your ears?*

YesNo
Anything else you would like to included in your dental history?

YesNo
If YES, please describe?
What is your main orthodontic concern?
Is there any other information that may be helpful?
Should be Empty:

PLEASE COMPLETE THE FOLLOWING

INSURANCE INFORMATION

PLAN 1

PLAN 2

EMERGENCY CONTACT

IF YOU ARE CURRENTLY UNDER ORTHODONTIC CARE

MEDICAL HISTORY

Dental History

Do you have or have had any of the following?