Adult Health & Insurance Information
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Preferred Name
Birthdate
Sex
Male
Female
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Employer and Occupation
Spouse name
Patient's Physician name and phone number
Patient's Dentist name and phone number
Date of last dental visit and reason
What orthodontic problem do you wish to have corrected?
Other family members seen by us
Have you seen another orthodontist? If yes, who?
Whom may we thank for referring you to our office?
Dental Insurance
Please provide all information so that we may verify benefits
Insured Name AND date of birth
Relationship to patient (self, child or spouse)
Employer name and group #
ID # or Social Security #
Insurance company- name, mailing address, phone #
Medical History
Latex Allergy
*
Yes
No
Drug Allergy
Yes
No
Hepatitis or Liver Problems
Yes
No
Tuberculosis
Yes
No
Rheumatic Fever
Yes
No
HIV/AIDS
Yes
No
Heart Disease
Yes
No
Heart Murmur
Yes
No
Cancer
Yes
No
Diabetes
Yes
No
Kidney Problems
Yes
No
Abnormal Bleeding/Hemophilia
Yes
No
Asthma
Yes
No
Bone Disorder
Yes
No
Sinus Problems
Yes
No
Epilepsy/Convulsions
Yes
No
Emotional Problems
Yes
No
Developmental Delays
Yes
No
High blood pressure
Yes
No
Wear Contact Lenses
Yes
No
Currently Pregnant
Yes
No
Is antibiotic pre-medication required prior to dental visits?
Yes
No
Other Comments
Are you in good health? If no, explain.
Is there any history of serious illness, accident or operations?
List any medications that you are taking and reason.
Dental History
Please check any that apply- give details below.
Grinding or clenching of teeth
Facial or jaw joint pain
Injury to mouth or teeth
Missing or extra teeth
Difficulty chewing
Speech problems
Thumbsucking- if yes, please provide age stopped below
None of the above
Details
Previous Periodontal treatment: date/location
Previous Orthodontic Treatment: date/location
Additional Information
Submit
Should be Empty: