Adult Registration Form Patient Information Gender MaleFemale Birth Date Primary Phone Number Phone type HomeCell Secondary Phone Number Phone type HomeCellOther NextSpouse/Emergency Contact Information Marital Status SingleMarriedDivorcedWidowedSignificant Others PreviousNextInsurance InformationPrimary Insurance Company Secondary Insurance Company PreviousNextDental History How did you hear about our Practice? AdInternetFamily or FriendPhysicianOther Have you visited an orthodontist before? YesNo Have your tonsils or adenoids been removed? YesNo Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? YesNo Do you have any missing or extra permanent teeth? YesNo Have you ever had an injury to (select all that apply): TeethMouthChin Do you have speech problems? YesNo Do your gums bleed? YesNo Do you smoke? YesNo Do you like your smile? YesNo Do you currently or have you ever had any of the following habits? Clenching/Grinding TeethLip Sucking/BitingMouth BreathingNail bitingThumb/ Finger SuckingChewing/Eating Problems PreviousNextMedical History Are you currently being treated by a physician? YesNo Do you have any allergies/sensitivities to medications or latex? YesNo Are you currently taking any prescription or over-the-counter medications? YesNo Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? YesNo Have you had any serious illnesses or operations? YesNo Have you ever had a blood transfusion? YesNo (Women) Are you pregnant? YesNo Nursing? YesNo Taking birth control pills? YesNo Check if you have or have ever had any of the following: Abnormal BleedingAnemiaArthritis, RheumatismArtificial Heart ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseBlood TransfusionCancerChemical DependencyChemotherapyCirculatory ProblemsCongenital Heart DefectCortisone TreatmentsCough, PersistentCoughing BloodDiabetesDifficulty BreathingDrug/Alcohol/AbuseEpilepsyEmphysemaFaintingFever Blisters/HerpesGlaucomaHeadachesHeart AttackHeart SurgeryHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHigh/Low Blood SugarHIV/AIDSHospitalized for Any ReasonJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerPsychiatric ProblemsRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShinglesShortness of BreathSickle Cell Disease/TraitsSinus ProblemsSkin RashStrokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease PreviousNextAuthorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my reponsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. Date Previous
