Stoll Orthodontics | Thornton CO

Adult New Patient

    Patient Information

    Are you an adult patient (18 years of age or older)?
    You have indicated that you are NOT an adult patient (18 years of age or oldeR) please complete our Child New Patient Form.
    Patient's Name
    Gender
    MaleFemale

    Birth Date

    Primary Phone Number

    Phone type
    HomeCell
    Secondary Phone Number

    Phone type
    HomeCellOther

    Spouse/Emergency Contact Information

    Marital Status
    SingleMarriedDivorcedWidowedSignificant Others


    Insurance Information

    Primary Insurance Company










    Secondary Insurance Company










    Dental History


    How did you hear about our Practice?
    AdInternetFamily or FriendPhysicianOther

    Have you visited an orthodontist before?
    YesNo

    Have your tonsils or adenoids been removed?
    YesNo
    Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?
    YesNo
    Do you have any missing or extra permanent teeth?
    YesNo
    Have you ever had an injury to (select all that apply):
    NoneTeethMouthChin
    Do you have speech problems?
    YesNo
    Do your gums bleed?
    YesNo
    Do you smoke?
    YesNo
    Do you like your smile?
    YesNo
    Do you currently or have you ever had any of the following habits?
    Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating ProblemsPacifier Usage

    Medical History

    Are you currently being treated by a physician?
    YesNo
    Do you have any allergies/sensitivities to medications or latex?
    YesNo
    Are you currently taking any prescription or over-the-counter medications?
    YesNo
    Have you had any serious illnesses or operations?
    YesNo
    (Women)
    Are you pregnant?
    YesNo
    Check if you have or have ever had any of the following:
    Abnormal BleedingAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseBlood TransfusionCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart DefectCortisone TreatmentsCough, PersistentCoughing BloodDiabetesDifficulty BreathingDrug/Alcohol/AbuseEpilepsyEmphysemaFaintingFever Blisters/HerpesGlaucomaHeadachesHeart AttackHeart SurgeryHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHigh/Low Blood SugarHIV/AIDSHospitalized for Any ReasonJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShinglesShortness of BreathSickle Cell Disease/TraitsSinus ProblemsSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

    Authorization



    Date