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PATIENT LOGIN
Adult Form
Adult Form
2020-09-16T13:26:59-04:00
Patient Name
Address
Town
Zip Code
Gender
Male
Female
Home Phone
Business Phone
Cell Phone
Email Address
Who Referred You?
Birth Date
Birthplace
Marital Status
Married
Single
Divorced
Separated
Widowed
Dentist's Name
Date Of Last Checkup
Physician's Name
Date Of Last Checkup
Your Occupation
Your Social Security
Employers Name & Address
Spouse's Name
Spouse's Occupation
Spouse's Employer Name & Address
Spouse's Date Of Birth
Spouse's Social Security
Spouse's Phone
Children's Names & Ages
Are Any Family Members Currently In Treatment?
Yes
No
If So, Why?
Currently Wearing Braces?
Yes
No
Currently Wearing Retainers?
Yes
No
Has An Appliance?
Yes
No
Invisalign?
Yes
No
Waiting To Begin Treatment?
Yes
No
1. What Are The Main Concerns That You Would Like Orthodontics To Accomplish?
2. Are You In Good Health?
Yes
No
3. Do You Have Regular Medical Examinations?
Yes
No
4. Have You Ever Had Any Of The Following? (Please Check)
Anemia
Hepatitis
Liver Or Kidney Disease
Diabetes
Hives
Jaw Pain
Asthma
Jaundice
Rheumatic Fever
Epilepsy
Pneumonia
Blood Disorders
Hay Fever
Heart Disease
Chronic Headaches
Hemophilia
Migraines
Fainting
Mitral Valve Prolapse
Handicaps Or Disabilities
HIV/AIDS
Cancer
Allergies To Any Drugs?
5. Do you require pre-medication for any condition, If so, What?
6. Is there anything else we should know about your general health? Such as allergies to medications, food, Latex, etc
7. Have you ever had any injuries to the face, mouth, teeth, or chin? If yes, please explain
8. Are you a mouth-breather? If yes, please explain
9. Is there a hereditary background that might contribute to your dental problem
Yes
No
10. Have you ever had any pain / tenderness in their jaw joint (TMJ)?
Yes
No
11. Other Remarks
13. Do you have Insurance?
14. Name Of Insurance Company?
By entering your initials, you are providing your signature electronically.
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