“Take a minute to review, print and fill out our adult information form

before your first visit to save you time on arrival!”

    PATIENT INFORMATION

    Name:

    Date:

    Date Of Birth M/D/Y:

    Age:

    Sex:

    Occupation:

    Home Address:

    City:

    Postal Code:

    Home Tel:

    Daytime Tel:

    Tel Type:

    E-mail address (to confirm appointments):

    Patient’s Dentist:

    Physician:

    Physician Tel:

    Who may we thank for referring you?

    Person Responsible for Account:

    If Person Responsible other than yourself, please indicate relationship

    Do you have an insurance plan that covers orthodontic treatment?

    YesNounsure

    MEDICAL HISTORY

    HAVE YOU BEEN TREATED FOR ANY OF THE FOLLOWING?
    Rheumatic Fever

    YesNo

    Tuberculosis

    YesNo

    Diabetes

    YesNo

    Heart Murmur

    YesNo

    H.I.V./A.I.D.S.

    YesNo

    Kidney Disorder

    YesNo

    Mitral Valve Prolapse

    YesNo

    Hepatitis A, B, or C

    YesNo

    Liver Disease

    YesNo

    Heart Disease

    YesNo

    Sexually Transmitted Diseases

    YesNo

    Asthma

    YesNo

    Artificial Heart Valve

    YesNo

    Blood Disease

    YesNo

    Arthritis

    YesNo

    Artificial Joints

    YesNo

    Prolonged Bleeding

    YesNo

    Other

    If you responded YES to any of the above, please give pertinent information:

    Are you in good health?

    If No please explain

    Do you have any history of major illness and/or operations?

    List any drugs or medication now being taken: Please give reasons:

    Are you currently taking or have you been given intravenous bisphosphonates (such as Zometa or Aredia) for bone cancer?

    YesNo

    Are you currently taking or have you been given oral or intravenous bisphosphonates (such as Fosamax, Actonel, Boniva, Reclast, Skelid, Didronel, or Bonefos) for osteoporosis, osteopenia, or other uses?

    YesNo

    List any allergies or drug sensitivities (Including sensitivity to metals):

    Do you have a tendency to colds?

    Sore Throats?

    Ear Infections?

    Have your tonsils or adenoids been removed?

    If so, at what age?

    (Women) Are you pregnant?

    DENTAL HISTORY

    Have you ever been treated for a jaw joint problem, including surgery?

    YesNo

    Please describe:

    Have there been any injuries to the face, mouth or teeth?

    YesNo

    Please describe:

    Have you ever sucked your thumb or finger?

    YesNo

    Until What age:

    Do you have any speech problems?

    YesNo

    Do you have frequent canker or cold sores?

    YesNo

    Are you a mouth breather? While Asleep:

    YesNo

    While Awake:

    YesNo

    Have you been informed of any missing or extra permanent teeth?

    YesNo

    Have you ever had a previous orthodontic examination?

    YesNo

    Has any other family member had braces or orthodontic treatments?

    YesNo

    If yes, name of family member if treated in our office:

    When did you last see your dentist?

    Reason for orthodontic consultation:

    RELEASE OF INFORMATION: I hereby give Dr. J. Daskalogiannakis and/or members of his staff permission to release information concerning my dental and/or orthodontic health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and other diagnostic records pertaining to the initial condition, diagnosis, proposed treatment or treatment in progress.

    Signature:

    Date

    If you’re unable to open PDF files, you can get Adobe Reader® for free.

    Problem retrieving data from Twitter