ADULT PATIENT FORM

ADULT PATIENT INFORMATION

Date

Patient’s name

Residence

Mailing Address

Phone

Cell Phone

Date of Birth

Email

Whom may we thank for referring you to our office?

MEDICAL HISTORY

Physician

Date of Last Visit

Address

Phone

Please circle Yes or No (If Yes, please fill in details)

Are you taking any medication?

YesNo

Are you allergic to any medication?

YesNo

Do you have a history of a major illness?

YesNo

Have you had any operations?

YesNo

Have you ever been involved in a serious accident?

YesNo

Have you ever smoked or chewed tobacco?

YesNo

Have seen a physician in the last 12 months? Why?

YesNo

Do you experience sleeping problems such as snoring or sleep apnea?

YesNo

Female Patients only:

Are you pregnant?

YesNo

Has menstruation started?

YesNo

Circle any of the medical conditions below that you have had or currently have.

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

What is the main reason for visiting an orthodontist?

Are you presently in any dental pain?

YesNo

Have your wisdom teeth been removed?

YesNo

Have you ever lost or chipped any teeth?

YesNo

Have there been any injuries to face, mouth, or teeth?

YesNo

Is any part of your mouth sensitive to temperature? Where?

YesNo

Is any part of your mouth sensitive to pressure? Where?

YesNo

Do your gums bleed when you brush?

YesNo

Do you have any type of thumb or tongue habit?

YesNo

Are you a mouth breather?

YesNo

Have you ever seen an orthodontist? If yes, who and when?

YesNo

Do your teeth or jaws ever feel uncomfortable when you awake in the morning?

YesNo

Are you aware of your jaw clicking or popping?

YesNo

Are you aware of clenching your teeth during the day?

YesNo

Have you ever been told that you grind your teeth?

YesNo

Have you ever experienced chronic ringing in your ears?

YesNo

Are you aware that some appointments will be during work hours?

YesNo