perlotorthodontics.com - Adult New Patient Form

GENERAL INFORMATION
What concerns you about your teeth?*
Who suggested that you might need orthodontic treatment?*
Why did you select our office?*
Have you had any previous orthodontic treatment? Please describe*
Have any other family members been treated in this office? Please name them.*
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.*
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email
example@example.com
Social Security #
Employer
DENTAL INSURANCE
Does the Patient have dental insurance?

YesNo
Primary policy holder's full name
Birth date

MonthDayYear
Date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID #
Does this policy have orthodontic benefits?

YesNoDon't know
Secondary policy holder's full name
Birth date

MonthDayYear
Date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group #
ID #
Does this policy have orthodontic benefits?

YesNoDon't know
MEDICAL INSURANCE
Policy holder's full name
Insurance company

	yes	no	dk/u
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?
Hereditary or developmental conditions?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections
Asthma, sinus problems, hay fever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

	yes	no	dk/u
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Food
Other substances

	yes	no	dk/u
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
"Gum boils," frequent canker sores or cold sores
History of speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

	Don't Know	No	Yes	If yes, explain
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

Other physicians/health care providers being seen now:

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY