New Patient Form | Adult | Spannhake Orthodontics

Gender Assigned At Birth

Male

Female

Date of birth

Preferred Pronouns

SSN#

Marital Status

Home phone

Cell Phone

Work phone

Occupation

Employer

Spouse or closest relative name

Address (if different than patients)

Home phone

Cell Phone

Work phone

Last seen

Reason

Next Appointment

OTHER DENTISTS/DENTAL SPECIALISTS NOW BEING SEEN (NAME, CITY, STATE)

Patients Physician

City

State

Last seen

Reason

Next Appointment

Most recent physical exam

Other physicians/health care providers being seen now:

WHAT CONCERNS YOU ABOUT YOUR TEETH?

WHO SUGGESTED THAT YOU MIGHT NEED ORTHODONTIC TREATMENT?

WHY DID YOU SELECT OUR OFFICE?

HAVE YOU HAD ANY PREVIOUS ORTHODONTIC TREATMENT? PLEASE DESCRIBE.

HAVE ANY OTHER FAMILY MEMBERS BEEN TREATED IN THIS OFFICE? PLEASE NAME THEM.

DO YOU THINK THAT ANY OF YOUR WORK OR LEISURE ACTIVITIES AFFECT YOUR TEETH OR JAWS? PLEASE EXPLAIN.

Financial Responsibility

WHO IS FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT?

ADDRESS (IF DIFFERENT FROM PAGE 1

Home phone (if different)

Cell phone

WHO WILL BE RESPONSIBLE FOR BRINGING THE PATIENT TO ORTHODONTIC APPOINTMENTS?

PRIMARY POLICY HOLDER’S FULL NAME

Birthdate

SSN#

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

DOES THIS POLICY HAVE ORTHODONTIC BENEFITS?

SECONDARY POLICY HOLDER’S FULL NAME

Birthdate

SSN#

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

DOES THIS POLICY HAVE ORTHODONTIC BENEFITS?

POLICY HOLDER’S FULL NAME

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (DKU).

Now or in the past, have you had:

BIRTH DEFECTS OR HEREDITARY PROBLEMS?

Yes

Don't Know

BONE FRACTURES, OR MAJOR INJURIES?

Yes

Don't Know

ANY INJURIES TO FACE, HEAD, NECK?

Yes

Don't Know

ARTHRITIS OR JOINT PROBLEMS?

Yes

Don't Know

CANCER, TUMOR, RADIATION TREATMENT OR CHEMOTHERAPY?

Yes

Don't Know

ENDOCRINE OR THYROID PROBLEMS?

Yes

Don't Know

DIABETES OR LOW SUGAR?

Yes

Don't Know

KIDNEY PROBLEMS?

Yes

Don't Know

IMMUNE SYSTEM PROBLEMS?

Yes

Don't Know

STOMACH ULCER, HYPERACIDITY, ACID REFLUX?

Yes

Don't Know

HISTORY OF OSTEOPOROSIS?

Yes

Don't Know

GONORRHEA, SYPHILIS, HERPES, SEXUALLY TRANSMITTED DISEASES?

Yes

Don't Know

AIDS OR HIV POSITIVE?

Yes

Don't Know

HEPATITIS, JAUNDICE OR OTHER LIVER PROBLEMS?

Yes

Don't Know

POLIO, MONONUCLEOSIS, TUBERCULOSIS, PNEUMONIA?

Yes

Don't Know

SEIZURES, FAINTING SPELLS, NEUROLOGIC PROBLEM?

Yes

Don't Know

MENTAL HEALTH DISTURBANCE OR DEPRESSION?

Yes

Don't Know

HISTORY OF EATING DISORDER (ANOREXIA, BULIMIA)?

Yes

Don't Know

FREQUENT HEADACHES OR MIGRAINES?

Yes

Don't Know

HIGH OR LOW BLOOD PRESSURE?

Yes

Don't Know

EXCESSIVE BLEEDING OR BRUISING TENDENCY, ANEMIA?

Yes

Don't Know

CHEST PAIN, SHORTNESS OF BREATH, TIRE EASILY, SWOLLEN ANKLES?

Yes

Don't Know

HEART DEFECTS, HEART MURMUR, RHEUMATIC HEART DISEASE?

Yes

Don't Know

ANGINA, ARTERIOSCLEROSIS, STROKE OR HEART ATTACK?

Yes

Don't Know

SKIN DISORDER (OTHER THAN COMMON ACNE)?

Yes

Don't Know

DO YOU EAT A WELL-BALANCED DIET?

Yes

Don't Know

VISION, HEARING, OR SPEECH PROBLEMS?

Yes

Don't Know

FREQUENT EAR INFECTIONS, COLDS, THROAT INFECTIONS?

Yes

Don't Know

ASTHMA, SINUS PROBLEMS, HAYFEVER?

Yes

Don't Know

TONSIL OR ADENOID CONDITION?

Yes

Don't Know

DO YOU FREQUENTLY BREATHE THROUGH YOUR MOUTH?

Yes

Don't Know

Have you had allergies or reactions to any of the following:

LOCAL ANESTHETICS (NOVOCAINE, LIDOCAINE, XYLOCAINE)

Yes

Don't Know

LATEX (GLOVES, BALLOONS)

Yes

Don't Know

ASPIRIN

Yes

Don't Know

IBUPROFIN (MOTRIN, ADVIL)

Yes

Don't Know

PENICILLIN

Yes

Don't Know

OTHER ANTIBIOTICS

Yes

Don't Know

METALS (JEWELRY, CLOTHING SNAPS)

Yes

Don't Know

ACRYLICS

Yes

Don't Know

PLANT POLLENS

Yes

Don't Know

ANIMALS

Yes

Don't Know

FOODS

Yes

Don't Know

OTHER SUBSTANCES

Yes

Don't Know

Have you had allergies or reactions to any of the following:

PERMANENT OR EXTRA (SUPERNUMERARY) TEETH REMOVED?

Yes

Don't Know

SUPERNUMERARY (EXTRA) OR CONGENITALLY MISSING TEETH?

Yes

Don't Know

CHIPPED OR INJURED PRIMARY OR PERMANENT TEETH?

Yes

Don't Know

ANY SENSITIVE OR SORE TEETH?

Yes

Don't Know

BLEEDING GUMS, BAD TASTE OR MOUTH ODOR?

Yes

Don't Know

JAW FRACTURES, CYSTS, INFECTIONS?

Yes

Don't Know

JAW FRACTURES, CYSTS, INFECTIONS?

Yes

Don't Know

ANY TEETH TREATED WITH ROOT CANALS OR PULPOTOMIES?

Yes

Don't Know

“GUM BOILS,” FREQUENT CANKER SORES OR COLD SORES?

Yes

Don't Know

HISTORY OF SPEECH PROBLEMS OR SPEECH THERAPY?

Yes

Don't Know

DIFFICULTY BREATHING THROUGH NOSE?

Yes

Don't Know

FOOD IMPACTION BETWEEN THE TEETH?

Yes

Don't Know

MOUTH BREATHING HABIT OR SNORING AT NIGHT?

Yes

Don't Know

HISTORY OF SPEECH PROBLEMS?

Yes

Don't Know

FREQUENT ORAL HABITS (SUCKING FINGER, CHEWING PEN, ETC.)?

Yes

Don't Know

TEETH CAUSING IRRITATION TO LIP, CHEEK OR GUMS?

Yes

Don't Know

ABNORMAL SWALLOWING (TONGUE THRUST)?

Yes

Don't Know

TOOTH GRINDING OR CLENCHING?

Yes

Don't Know

CLICKING, LOCKING IN JAW JOINTS?

Yes

Don't Know

SORENESS IN JAW MUSCLES OR FACE MUSCLES?

Yes

Don't Know

RINGING IN EARS, DIFFICULTY IN CHEWING OR OPENING JAW?

Yes

Don't Know

HAVE YOU EVER BEEN TREATED FOR “TMJ” OR “TMD” PROBLEMS?

Yes

Don't Know

ANY BROKEN OR MISSING FILLINGS?

Yes

Don't Know

ANY SERIOUS TROUBLE ASSOCIATE WITH PREVIOUS DENTAL TREATMENT?

Yes

Don't Know

HAVE YOU EVER BEEN DIAGNOSED WITH GUM DISEASE OR PYORRHEA?

Yes

Don't Know

HAVE YOU EVER HAD AN ORTHODONTIC CONSULTATION OR TREATMENT BEFORE NOW?

Yes

Don't Know

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Medication

Taken for

Medication

Taken for

Medication

Taken for

HAVE YOU EVER TAKEN ANY MEDICATIONS TO STRENGTHEN YOUR BONES? PLEASE DESCRIBE.

DO YOU OR HAVE YOU EVER HAD A SUBSTANCE ABUSE PROBLEM?

DO YOU CHEW OR SMOKE TOBACCO?

HAVE YOU NOTICED ANY CHANGES IN YOUR FACE OR JAWS?

ANY OTHER PHYSICAL PROBLEMS?

HOW OFTEN DO YOU BRUSH?

HOW OFTEN DO YOU FLOSS?

Please list all drugs/things that your child is allergic to

ARE YOU TRYING TO BECOME PREGNANT?

Family Medical History

HAVE YOUR PARENTS OR SIBLINGS EVER HAD ANY OF THE FOLLOWING HEALTH PROBLEMS? IF SO, PLEASE EXPLAIN.

Have the parents or siblings ever had any of the following health problems? If so, please explain.

UNUSUAL DENTAL PROBLEMS

OTHER FAMILY MEDICAL CONDITIONS?

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

Medical Dental History Form for Adult Patient