Existing Patient Update Form

Existing Patient Update Form - Adult
Patient Information
Date

MonthDayYear
Date
Patient's Full Name

First NameMiddle NameLast Name
Prefers to be called
Birthdate

MonthDayYear
Date
Gender

MaleFemale
SS #
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Number
Please enter a valid phone number.
Email
example@example.com
Employer/Occupation
How long?
General Information
What concerns you about your teeth?
How do you feel about orthodontic treatment?
Who suggested you might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment.
Dentist
Patient's Dentist
Dental Practice's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen

MonthDayYear
Date
Reason
Other dentist/dental specialists now being seen
Reason
Insurance

Orthodontic/Dental Insurance
Primary Policy Holder's Full Name

First NameLast Name
Primary Policy Holder's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Policy Holder's Cell Number
Please enter a valid phone number.
Primary Policy Holder's SS #
Relationship to Patient
DOB

MonthDayYear
Date
Employer
Primary Policy Holder's Email
example@example.com
Insurance Company
Group #
ID #
Does this policy have orthodontic coverage?

YesNo
Your answes are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontics evaluation.

For the following questions, please mark yes, no, or don't know/understand (DK/U).
Medical History

Now or in the past, have you had:
Birth defects or hereditary problems?

YesNoDK/U
Bone fractures or major injuries?

YesNoDK/U
Any injuries to face, head, neck?

YesNoDK/U
Arthritis or joint problems?

YesNoDK/U
Endocrine or thyroid problems?

YesNoDK/U
Diabetes or low sugar?

YesNoDK/U
Kidney problems?

YesNoDK/U
Cancer, tumor, radiation treatment or chemotherapy?

YesNoDK/U
Stomach ulcer, hyperacidity, acid reflux?

YesNoDK/U
Immune system problems?

YesNoDK/U
History of osteoporosis?

YesNoDK/U
Gonorrhea, syphilis, herpes, sexually transmitted diseases?

YesNoDK/U
AIDS or HIV positive?

YesNoDK/U
Hepatitis, jaundice, or other liver problems?

YesNoDK/U
Polio, mononucleosis, tuberculosis, pneumonia?

YesNoDK/U
Seizures, fainting spells, neurologic problems?

YesNoDK/U
Mental health disturbance or depression?

YesNoDK/U
Vision, hearing, or speech problems?

YesNoDK/U
History of eating disorder (anorexia, bulimia)?

YesNoDK/U
High or low blood pressure?

YesNoDK/U
Excessive bleeding or bruising, anemia?

YesNoDK/U
Chest pain, shortness of breath, tire easily, swollen ankles?

YesNoDK/U
Heart defects, heart murmur, rheumatic heart disease?

YesNoDK/U
Angina, arteriosclerosis, stroke or heart attack?

YesNoDK/U
Skin disorder (other than common acne)?

YesNoDK/U
Do you eat a well-balanced diet?

YesNoDK/U
Frequent headaches or migraines?

YesNoDK/U
Frequent ear infections, colds, throat infections?

YesNoDK/U
Asthma, sinus problems, hayfever?

YesNoDK/U
Tonsil or adenoid condition?

YesNoDK/U
Do you frequently breathe through your mouth?

YesNoDK/U
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)

YesNoDK/U
Latex (gloves, balloons)

YesNoDK/U
Aspirin

YesNoDK/U
Metals (jewelry, clothing snaps)

YesNoDK/U
Penicillin

YesNoDK/U
Other antibiotics

YesNoDK/U
Ibuprofen (Motrin, Advil)

YesNoDK/U
Acrylics

YesNoDK/U
Plant pollens

YesNoDK/U
Animals

YesNoDK/U
Foods

YesNoDK/U
Other Substance(s)
Dental History

Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?

YesNoDK/U
Supernumerary (extra) or congenitally missing teeth?

YesNoDK/U
Chipped or injured primary or permanent teeth?

YesNoDK/U
Any sensitive or sore teeth?

YesNoDK/U
Bleeding gums, bad taste or mouth odor?

YesNoDK/U
Jaw fractures, cysts, infections?

YesNoDK/U
Any teeth treated with root canals or pulpotomies?

YesNoDK/U
“Gum boils,” frequent canker sores or cold sores?

YesNoDK/U
History of speech problems or speech therapy?

YesNoDK/U
Difficulty breathing through nose?

YesNoDK/U
Food impaction between the teeth?

YesNoDK/U
Mouth breathing habit or snoring at night?

YesNoDK/U
Frequent oral habits (sucking finger, chewing pen, etc)?

YesNoDK/U
Teeth causing irritation to lip, cheek or gums?

YesNoDK/U
Abnormal swallowing (tongue thrust)?

YesNoDK/U
Tooth grinding or clenching?

YesNoDK/U
Clicking, locking in jaw joints?

YesNoDK/U
Soreness in jaw muscles or face muscles?

YesNoDK/U
Ringing in ears, difficulty in chewing or opening jaw?

YesNoDK/U
Have you ever been treated for “TMJ” or “TMD” problems?

YesNoDK/U
Any broken or missing fillings?

YesNoDK/U
Any serious trouble associated with previous dental treatment?

YesNoDK/U
Have you ever been diagnosed with gum disease or pyorrhea?

YesNoDK/U
Have you ever had an orthodontic consultation or treatment before now?

YesNoDK/U
Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
Medication
Taken For
Medication
Taken For
Medication
Taken For
Have you ever taken any medications to strengthen your bones? Please describe:
Do you take antibiotic pre-medication before any dental procedures?
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Have you noticed any changes in your face or jaws?
How often do you brush?
How often do you floss?
Women: Are you pregnant?

YesNo
Are you trying to become pregnant?

YesNo
Family Medical History

Have your parents or siblings ever had any of the following health problems? If so, please explain:
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
Release and Waiver
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Medical History Updates/Changes
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date
Changes
Signature
Date

MonthDayYear
Date
Dental Staff Signature
Date

MonthDayYear
Date

Existing Patient Update Form - Adult

Patient Information

General Information

Dentist

Insurance

Medical History

Dental History

Patient Health Information

Family Medical History

Release and Waiver

Medical History Updates/Changes

Acknowledgement of Receipt of Notice of Privacy Practices