Adult New Patient Patient Information Are you an adult patient (18 years of age or older)? Yes No Patient's Name Gender Male Female Social Security Number Date of Birth Home Address City State Zipcode Primary Phone Number Phone type Home Cell Secondary Phone Number Phone type Home Cell Other Email Address Employer's Name Spouse/Emergency Contact Information Marital Status Single Married Divorced Widowed Significant Other Spouse/Partner's Name Emergency Contact Name Phone Number Relation to You Street Address City State Zipcode Person(s) OK to release appointment or medically related information to concerning you: Name(s) Relation to You Insurance Information Primary Insurance Insurance Company Name Phone Number Group Number Policy Number Member ID Number Policy Holder's Name Relation to You Policy Holder's Social Security Number Policy Holder's Date of Birth Policy Holder's Employer Secondary Insurance Insurance Company Name Phone Number Group Number Policy Number Member ID Number Policy Holder's Name Relation to You Policy Holder's Social Security Number Policy Holder's Date of Birth Policy Holder's Employer Dental History General Dentist Date of Last Visit How did you hear about our Practice? Ad Internet Family or Friend Physician Other Name of Person Referring (if applicable) What are the main concerns you would like orthodontics to accomplish? Have you visited an orthodontist before? Yes No When? For what reason? Have your tonsils or adenoids been removed? Yes No Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No Do you have any missing or extra permanent teeth? Yes No Have you ever had an injury to (select all that apply): None Teeth Mouth Chin Do you have speech problems? Yes No If yes, please explain: Do your gums bleed? Yes No Do you smoke? Yes No Do you like your smile? Yes No Do you currently or have you ever had any of the following habits? None Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing Nail Biting Thumb/ Finger Sucking Chewing/Eating Problems Pacifier Usage Medical History Are you currently being treated by a physician? Yes No Reason Do you have any allergies/sensitivities to medications or latex? Yes No If yes, please list allergies: Are you currently taking any prescription or over-the-counter medications? Yes No If yes, please list medications and dosages: Have you had any serious illnesses or operations? Yes No If yes, please describe: Are you pregnant? Yes No Check if you have or have ever had any of the following: None Abnormal Bleeding Anemia Arthritis/Rheumatism Artificial Heart Valves Artificial Joints Asthma Back Problems Blood Disease Blood Transfusion Cancer Chemical Dependency Chemotherapy Circulatory Problems Congenital Heart Defect Cortisone Treatments Cough, Persistent Coughing Blood Diabetes Difficulty Breathing Drug/Alcohol Abuse Epilepsy Emphysema Fainting Fever Blisters/Herpes Glaucoma Headaches Heart Attack Heart Surgery Heart Murmur Heart Problems Hemophilia Hepatitis High Blood Pressure High/Low Blood Sugar HIV/AIDS Hospitalized for Any Reason Jaw Pain Kidney Disease Liver Disease Mitral Valve Prolapse Pacemaker Psychiatric Problems Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever Shingles Shortness of Breath Sickle Cell Disease/Traits Sinus Problems Skin Rash Stroke Swelling of Feet or Ankles Thyroid Problems Tobacco Habit Tonsillitis Tuberculosis Ulcer Venereal Disease Authorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. I agree I disagree Signature of Patient/Responsible Party Date Send
