Adult Patient Information Form

Adult Patient Information Form
Date

MonthDayYear
Date
Patient's Name

First NameLast Name
Residential Address

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?
Previous Address (If less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
DOB

MonthDayYear
Date
Social Security No.
Email
example@example.com
Marital Status
Employer
Occupation
No. of Years Employed
Spouse's Name
Relationship to Patient
Employer
Occupation
No. of Years Employed
Social Security No.
DOB

MonthDayYear
Date
Work Phone
Please enter a valid phone number.
Whom may we thank for referring you to our office?
Dental Insurance Information
Insured's Name
Insured's Social Security No.
Insurance Company
Group No.
Local No.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Do you have dual coverage?

YesNo
Insured's Name
Insured's Social Security No.
Insurance Company
Group No.
Local No.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Emergency Information
Name of Nearest Relative Not Living With You
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
I understand that, where appropriate, credit bureau reports may be obtained.
Signature

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Date

MonthDayYear
Date
Medical History
Physician
Date of Last Visit

MonthDayYear
Date
What concerns you most about your teeth?
Are you taking any medication?

YesNo
Please describe:
Are you allergic to any medication?

YesNo
Please describe:
Do you have a history of a major illness?

YesNo
Please describe:
Have you had any major medical operations?

YesNo
Please describe:
Have you ever been involved in a serious accident?

YesNo
Please describe:
Have you ever smoked or chewed tobacco?

YesNo
Please describe:
Have you seen a physician in the last 12 months?

YesNo
Please describe:
Female Patients Only: Are you pregnant?

YesNo
Please describe:
Has menstruation begun?

YesNo
Please check any of the following medical conditions that you have had or currently have.

Abnormal Bleeding/HemophiliaAnemiaArthritisAsthma or Hay FeverBone DisordersCongenital Heart DefectDiabetesDizzinessEpilepsyGastrointestinal DisordersHeart ProblemsHeart MurmurHepatitis/Liver ProblemsHerpesHigh Blood PressureHIV/AIDSKidney ProblemsNervous DisordersPneumoniaProlonged BleedingRadiation/ChemotherapyRheumatic FeverTuberculosisTumor/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
Are you presently in any dental pain?

YesNo
Please describe:
Have you ever experienced any unfavorable reaction to dentistry?

YesNo
Please describe:
Have your wisdom teeth been removed?

YesNo
Please describe:
Have you ever lost or chipped any teeth?

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

YesNo
Please describe:
Is any part of your mouth sensitive to temperature?

YesNo
Please describe:
Is any part of your mouth sensitive to pressure?

YesNo
Please describe:
Do your gums bleed when you brush?

YesNo
Please describe:
Do you have any type of thumb or tongue habit?

YesNo
Please describe:
Are you a mouth breather?

YesNo
Please describe:
Have you ever seen an orthodontist?

YesNo
If yes, who and when?
What is your attitude toward receiving orthodontic treatment?
Has anyone in your family received orthodontic treatment?

YesNo
How did they feel about the result?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

YesNo
Please describe:
Are you aware of your jaw clicking or popping?

YesNo
Please describe:
Are you aware of clenching your teeth during the day?

YesNo
Please describe:
Have you ever been told that you grind your teeth?

YesNo
Please describe:
Do you have "tension" headaches?

YesNo
Please describe:
Have you ever experienced chronic ringing in your ears?

YesNo
Please describe:
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 the doctors to perform a complete orthodontic evaluation.
Signature

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Date

MonthDayYear
Date
Should be Empty:

Adult Patient Information Form

Dental Insurance Information

Emergency Information

Medical History

Dental History

Benefits