New Adult Patient Information - Stoll Orthodontics

1Patient Information

2Emergency Information

3Insurance Information

4Dental History

5Medical History

6Acknowledgement

Are you an adult patient (18 years of age or older)?(Required)

Yes

Patient Name(Required)

Sex(Required)

Male

Female

Date of Birth(Required)

MM slash DD slash YYYY

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone

Phone Type

Home

Cell

Other

Email Address(Required)

Employer's Name

Marital Status

Single

Married

Divorced

Widowed

Significant Other

Spouse/Partner's Name

Emergency Contact Name

Phone Number

Relation to You

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Insurance

Primary Insurance Company

Phone

Primary Group Number

Primary Policy Number

Primary Member ID Number

Primary Policy Holder's Name

Relation To You

Primary Policy Holder's Social Security Number

Primary Policy Holder's Date of Birth

MM slash DD slash YYYY

Primary Policy Holder's Employer

Secondary Insurance

Insurance Company Name

Phone

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

MM slash DD slash YYYY

Policy Holder's Employer

General Dentist

Date of Last Visit

MM slash DD slash YYYY

How did you hear about our Practice?

Social Media

Online Search

Referral

Physician

Other

Name of Person Referring

What are the main concerns you would like orthodontics to accomplish?

Have you visited an orthodontist before?

Yes

Date of Visit

MM slash DD slash YYYY

Reason For Visit

Have your tonsils or adenoids been removed?

Yes

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?

Yes

Have you ever had an injury to (Select all that apply):

None

Teeth

Mouth

Chin

Do you have speech problems?

Yes

If Yes, please explain:

Do your gums bleed?

Yes

Do you smoke?

Yes

Do you like your smile?

Yes

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

Are you currently being treated by a physician?

Yes

Reason

Do you have any allergies/ sensitivities to medications or latex?

Yes

Please list allergies

Are you currently taking any prescription or over-the-counter medications?

Yes

Please list medications and dosages:

Have you had any serious illnesses or operations?

Yes

Please describe:

Are you pregnant?

Yes

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

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

Today

MM slash DD slash YYYY

New Adult Patient Information Form

Primary Insurance

Secondary Insurance

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