ADULT ORTHODONTIC CONSULTATION FORM
(PLEASE PRINT) DATE______
PATIENT’S NAME ______
SURNAME GIVEN NAME INITIAL PREFERED
DATE OF BIRTH ______AGE ______GENDER ______
MONTH/DAY/YEAR
ADDRESS ______
NO. STREETCITY OR TOWNPOSTAL CODE
HOME # ______WORK # ______CELL#______
EMAIL ADDRESS:______
NAME OF EMPLOYER______
WHO REFERRED YOU TO THIS OFFICE? ______
WHO FIRST NOTICED THE NEED FOR ORTHODONTIC CARE? ______
REASON FOR ORTHODONTIC CONSULTATION ______
______
HAVE YOU HAD PREVIOUS ORTHODONTIC TREATMENT? □ YES□ NO
FOR YOU TO HAVE ORTHODONTIC THERAPY, DO YOU CONSIDER IT: □ Necessary □ Important □ Desirable □ Indifferent
DO YOU HAVE ANY CONCERNS REGARDING ORTHODONTIC TREATMENT?
______
HAS ANYONE ELSE IN THE FAMILY HAD OR HAVING ORTHODONTIC THERAPY? ______
IF YES, WHO? ______WHEN? ______AND BY WHOM? ______
HOW HAPPY ARE YOU ABOUT THE TREATMENT RESULTS? ______
______
PERSON FINANCIALLY RESPONSIBLE: □ THE PATIENT OR
NAME ______
SURNAMEGIVEN NAME
ADDRESS ______
NO. STREET CITY OR TOWN POSTAL CODE
HOME PHONE ______BUS. PHONE ______NAME OF EMPLOYER______
DO YOU HAVE INSURANCE, IF SO NAME OF INSURANCE______
NAME OF POLICY HOLDER ______
MEDICAL HISTORY
(PLEASE EXPLAIN ALL “YES” ANSWERS)
PHYSICIAN’S NAME ______
ADDRESS ______PHONE ______
CURRENTLY UNDER PHYSICIAN’S CARE? □ NO □ YES______
CURRENTLY TAKING MEDICATION?□ NO □ YES______
CURRENTLY UNDER PSYCHOLOGICAL GUIDANCE?□ NO □ YES______
DO YOU HAVE ANY OF THE FOLLOWING ILLNESSES?
JAUNDICE□ NO □ YES ______
HEPATITIS□ NO □ YES______
RHEUMATIC FEVER□ NO □ YES______
OVER→
MEDICAL HISTORY CON’T
OTHER SEVERE ILLNESSES□ NO □ YES______
REMOVAL OF TONSILS AND/OR ADENOIDS□ NO □ YES______
OTHER OPERATIONS □ NO □ YES______
DO YOU HAVE ANY OF THE FOLLOWING CONDITIONS?
AIDS OR CARRIER OF THE AIDS VIRUS? □ NO □ YES______
ASTHMA□ NO □ YES______
ALLERGIES - INCLUDING LATEX OR NICKEL□ NO □ YES______
BIRTH DEFECTS□ NO □ YES______
BLOOD DISORDERS □ NO □ YES______
EPILEPSY□ NO □ YES______
DIABETES□ NO □ YES______
HEART AND/OR LUNG CONDITIONS□ NO □ YES______
FREQUENT □ COLDS □ SORE THROATS□ NO □ YES______
PREGNANT OR THE POSSIBLITY□ NO □ YES______
OTHER MEDICAL CONDITIONS NOT LISTED□ NO □ YES______
MECICATIONS: □ NO □ YES______
DENTAL HISTORY
(PLEASE EXPLAIN ALL “YES” ANSWERS)
DENTIST’S NAME ______
ADDRESS ______PHONE ______
HOW LONG HAVE YOU BEEN GOING TO THE ABOVE DENTIST? ______
HOW OFTEN DO YOU GO TO YOUR DENTIST? ______
WHEN WAS YOUR LAST DENTIST APPOINTMENT? ______
HAVE YOU HAD A RECENT ORTHODONTIC EXAMINATION? ______
DO YOU OR DID YOU HAVE ANY OF THE FOLLOWING
INJURY TO HEAD, FACE, MOUTH OR TEETH?□ NO □ YES______
CLICKING OR DISCOMFORT IN THE JAW?□ NO □ YES______
GRINDING OR CLENCHING OF TEETH? □ NO □ YES______
RECURRENT HEADACHES?□ NO □ YES______
DIFFICULTY IN CHEWING? □ NO □ YES______
SPEECH PROBLEMS? □ NO □ YES______
EXTENSIVE DENTAL WORK OR GUM PROBLEMS?□ NO □ YES______
ARE YOU CONCERNED OR HAVE RESERVATIONS ABOUT
APPREARANCE OF YOUR □ FACE □ LIPS □ GUM □ TEETH?□ NO □ YES______
WEARING □ BRACES □ NO □ YES______
CO-OPERATION FOR APPROX. 2 YEARS?□ NO □YES______
APPOINTMENTS DURING BUSINESS HRS?□ NO □ YES______
SIGNATURE ____________
PLEASE NOTE: IT IS IMPORTANT THAT YOU COMPLETE AND BRING THIS FORM TO YOUR APPOINTMENT OR YOU CAN FAX IT TO (709)-489-1435 OR EMAIL:
IT IS THE POLICY OF THIS OFFICE TO BILL AND RECEIVE FULL PAYMENT FROM OUR PATIENTS. WE REQUIRE THAT YOU MAKE PAYMENTS FROM YOUR INSURANCE COMPANY PAYABLE TO YOU. WE HAVE STANDARD FORMS IN OUR OFFICE FOR YOUR USE.