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Adult New Patient Information

Adult New Patient Information

Patient Information

*Patient Name:

Gender Male Female

Social Security Number:
Birth Date:
Home Address:
City, State & Zip
Primary Phone Number
Primary Phone Number Secondary Phone Number
Secondary Phone Number *E-mail Address:
Employer and Occupation

Spouse/Emergency Contact Information

Marital Status Single Married Divorced Widowed Significant Other

Spouse/Partners Name:
Phone Number
Relation to you

Insurance Information

Primary Insurance Company:

Group Number:

Policy Number:

Member ID Number:

Policy Holders Name:

Relationship to Patient

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Work Phone Number:

Secondary Insurance Company

Phone Number:

Group Number:

Policy Number:

Member ID Number:

Policy Holder's Name:

Relationship to Patient

Policy Holders Social Security Number

Policy Holders Birth Date

Employer

Work Phone Number

Dental History

General Dentist Last Visit:

How did you hear about our Practice? Ad Internet Family or Friend Physician Dentist Other
Name of person referring (if applicable)

What are the main concerns you would like orthodontics to accomplish? What are the main concerns you would like orthodontics to accomplish?

Have you visited an orthodontist before? Yes No

Have your tonsils or adenoids been removed? Yes No

Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)? Yes No

Do you have any missing or extra permanent teeth? Yes No

Have you ever had an injury to (select all that apply): Teeth Mouth Chin

Do you have speech problems? Yes No
If so, explain:

Do your gums bleed? Yes No

Do you like your smile? Yes No

Do you currently or have you ever had any of the following habits?

Clenching/Grinding Teeth Lip Sucking/Biting Mouth Breathing

Nail biting Thumb/Finger Sucking Chewing/Eating Problems

Medical History

Are you currently being treated by a physician? Yes No
Reason
Physician

Do you have any allergies/sensitivities to medications or latex? Yes No
If yes, please list allergies:

Are you currently taking any prescription or over-the-counter medications? Yes No
Please list, with dosage:

Have you had any serious illnesses or operations? If yes, describe: Have you had any serious illnesses or operations? If yes, describe:

Check if you have or have ever had any of the following:

Anemia Arthritis Asthma Back Problems Cancer Diabetes Epilepsy Fainting Glaucoma Headaches Heart Problems

Hepatitis High Blood Pressure Jaw Pain Scarlet Fever Stroke Tonsillitis Tuberculosis

Authorization

The information that I have given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.

Patient Signature and/or Responsible Party

Date:

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Alameda Orthodontics

Alameda Orthodontics - 2100 Otis Dr., Suite F Alameda, CA 94501 Phone: 510-521-4822

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