Dr. Ferris

Adult Registration Form

Patient Information

Gender
MaleFemale

Birth Date

Primary Phone Number

Phone type
HomeCell
Secondary Phone Number

Phone type
HomeCellOther

Spouse/Emergency Contact Information

Marital Status
SingleMarriedDivorcedWidowedSignificant Others


Insurance Information

Primary Insurance Company













Secondary Insurance Company













Dental 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

Medical 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

Authorization



Date