"*" indicates required fields New Adult Patient InformationPatientName:* First Middle Last Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Age*Sex*Email* Phone*Occupation*Company Name*Work PhoneOther phone:Dentist:*Referred to us by:*Marital Status: Married Separated Divorced Remarried Widowed Name and Age of any children in the family:Spouse or Partner’s Name: Complete Name EmploymentList Interests/ Sports/ Hobbies:Favorite TV/MovieFavorite Music:Do you have dental insurance coverage?* Yes No Dental Insurance Company:Contact #Insurance Claims Address:Subscriber Name: Complete Name Date of Birth: MM slash DD slash YYYY Subscriber SSN:Subscriber ID #:Group #:Medical HistoryFor the following questions mark yes, no or don’t know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation. Patient Profile: Does patient follow directions well?* Yes No DK/U Does the patient brush their teeth conscientiously?* Yes No DK/U Does the patient have learning disabilities or need extra help with instruction? Is the patient self conscience or sensitive about their teeth?* Yes No DK/U Does the patient have any sensory issues?* Yes No DK/U Medical History: Now or in the past, have you had any of the following: Birth defects or heredity problems* Yes No DK/U Bone fractures, any major accident* Yes No DK/U Rheumatoid or arthritic conditions* Yes No DK/U Endocrine or thyroid problems* Yes No DK/U Kidney problems* Yes No DK/U Diabetes* Yes No DK/U Cancer, tumor radiation or chemotherapy* Yes No DK/U Stomach ulcer or hyperacidity* Yes No DK/U AIDS or HIV positive* Yes No DK/U Hepatitis, jaundice or liver problems* Yes No DK/U Fainting spells,seizures, epilepsy or neurological problems* Yes No DK/U Mental health disturbance or depression* Yes No DK/U Vision, hearing, taste or speech difficulties* Yes No DK/U Loss of weight recently, or poor appetite* Yes No DK/U History of eating disorder* Yes No DK/U Excessive bruising, anemia or bleeding disorder* Yes No DK/U High or low blood pressure* Yes No DK/U Cardiovascular problems* Yes No DK/U Skin disorder* Yes No DK/U Frequent headaches, colds or sore throat* Yes No DK/U Ear, nose or throat condition* Yes No DK/U Hayfever, asthma, sinus trouble or hives* Yes No DK/U Tonsil or adenoid conditions* Yes No DK/U Allergies or reactions to any of the following: Local anesthetics (Novocaine or Lidocaine)* Yes No DK/U Aspirin* Yes No DK/U Ibuprofen (Motrin, Advil)* Yes No DK/U Penicillin or other antibiotics* Yes No DK/U Sulfa drugs* Yes No DK/U Codeine or other narcotics* Yes No DK/U Metals (jewelry, clothing snaps)* Yes No DK/U Latex (gloves, balloons)* Yes No DK/U Vinyl* Yes No DK/U Acrylic* Yes No DK/U Animals* Yes No DK/U Foods* Yes No DK/U specifyOther substances* Yes No DK/U specifyDoes the patient currently have or ever had a substance abuse problem?* Yes No DK/U Does the patient chew or smoke tobacco?* Yes No DK/U Is the patient taking medication, nutrient supplements, Herbal medications or non-prescription medicine?* Yes No DK/U Please name them:MedicationTaken for:MedicationTaken for:Operations?* Yes No DK/U DescribeHospitalized for?:Other physical problems or symptoms? Describe:Being treated by another health care professional? For:Date of most recent physical exam?Are there any other medical conditions that we should be made aware of?Girls only:Has the patient started her monthly periods? If so,approximately when?Is the patient pregnant?Family Medical History: Do your parents or siblings have any of the following health problems? If so, please explain: Bleeding disorders Unusual dental problems Diabetes Arthritis Jaw size imbalance Severe allergiesAny other family medical conditions that we should know about?Dental HistoryNow or in the past, has the patient had:Started teething very early or late* Yes No DK/U Primary (baby) teeth removed that were not loose* Yes No DK/U Permanent or “extra” (supernumerary) teeth removed* Yes No DK/U Supernumerary (extra) or congenitally missing teeth* Yes No DK/U Chipped or otherwise injured primary (baby) or permanent teeth* Yes No DK/U Teeth sensitive to hot or cold; teeth throb or ache* Yes No DK/U Jaw fractures, cysts or mouth infections* Yes No DK/U “Dead teeth” or root canals treated Bleeding gums, bad taste or odor in the mout* Yes No DK/U snore more than half the time?* Yes No DK/U Bleeding gums, bad taste or odor in the mouth* Yes No DK/U Periodontal “gum problems”* Yes No DK/U Food impaction between teeth* Yes No DK/U Thumb, finger or sucking habit* Yes No DK/U Until what age?Abnormal swallowing habit (tongue thrusting)* Yes No DK/U History of speech problems* Yes No DK/U Mouth breathing habit, snoring or difficulty in breathing* Yes No DK/U Tooth grinding or jaw clenching* Yes No DK/U Any pain in jaw or ringing in the ears* Yes No DK/U Any pain or soreness in the muscles of the face or around the ears* Yes No DK/U Difficulty in chewing or jaw opening* Yes No DK/U Aware of loose, broken or missing restoration (fillings)* Yes No DK/U Any teeth irritating cheek, lip, tongue or palate* Yes No DK/U Concerned about spaced, crooked or protruding teeth* Yes No DK/U Aware or concerned about under or over developed jaw* Yes No DK/U “Gum boils”, frequent canker sores or cold sores* Yes No DK/U Taking any forms of fluoride* Yes No DK/U Had periodontal (gum) treatment* Yes No DK/U Would the patient object to wearing orthodontic appliances (braces) should they be indicated? Any serious trouble associated with any previous dental treatment* Yes No DK/U Ever had a prior orthodontic examination or treatment* Yes No DK/U Been under another dentist’s care?* Yes No DK/U SpecialistOtherHow often does your child brush:FlossWhat is your primary concern:Why is your child here?How did you hear about us?Consent* I agreeI have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes made later to this history record or medical/dental status, I will so inform this practice. Patient/Responsible Party Complete Name Date MM slash DD slash YYYY Dental staff member Complete Name Date MM slash DD slash YYYY Notice of Privacy NoticesThis form is optional under the new patient privacy regulations recently issued by the United States Department of Health and Human Services. We have elected to use the form. Prior to commencing your orthodontic treatment, you should review, sign and date this form. Your protected health information (i.e. individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e. performance reviews, certification, accreditation and licensure). You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent. Thank you for your cooperation. Please let us know if you have any questionsPatient’s Print Name: First Last Date MM slash DD slash YYYY Responsible Party (if not patient):Relationship to patient:Date MM slash DD slash YYYY Acknowledgement of Receipt of Notice of Privacy NoticesI have received a copy of this office’s Notice of Privacy Practices.Print Name:Date MM slash DD slash YYYY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (please specify): Please Specify