PATIENT INFORMATION FOR ADULTS


Name *
Name
Residence *
Residence
Mailing Address
Mailing Address
(if different from residence)
Previous Address
Previous Address
(if less than 3 years)
Home Phone *
Home Phone
Work Phone
Work Phone
Cell / Other
Cell / Other
Birthdate *
Birthdate
Marital Status
DENTAL INSURANCE INFORMATION
Insured's Name
Insured's Name
Insurance Co. Address
Insurance Co. Address
Insurance Co. Phone
Insurance Co. Phone
Do you have dual coverage?
If Yes, complete fields below
EMERGENCY INFO
Nearest Relative Not Living with You
Nearest Relative Not Living with You
Address
Address
Phone
Phone
DENTAL HISTORY
Are you presently in any dental pain?
Ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth, or teeth?
Do gums bleed when brushing?
Any type of thumb tongue habit?
Are you a mouth breather?
Have you ever seen an orthodontist?
Has anyone in the family received orthodontic treatment?
Do teeth or jaws ever feel uncomfortable first thing in the morning?
Experience jaw clicking or popping?
Aware of clenching or grinding teeth during the day?
Experience “tension” headaches?
Have you ever experienced chronic ringing in the ears?
Are you aware that some appointments will be during work hours?
MEDICAL HISTORY
Physician's Address
Physician's Address
Physician's Phone
Physician's Phone
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of a major illness?
Have you had any operations?
Have you ever been involved in a serious accident?
Have you ever smoked or chewed tobacco?
Have seen a physician in the last 12 months?
Female Patients: Are you pregnant?
Female Patients: Has menstruation started?
Check any of the conditions below that you have had or currently have:
BENEFITS
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Aszkler to perform a complete orthodontic evaluation. *
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Aszkler to perform a complete orthodontic evaluation.
Agree by typing signature below