Confidential Adult Patient Health History & Information

Patient Information

Date

Last

First

Middle

Address (Street, City, State, Zip)

Nickname

Birth Date

Age

Gender

Male

Female

SSN#

Home Phone

Work Phone

Mobile Phone

Email address we can use for appointment reminders

Whom may we thank for referring you to our office?

Employer

Occupation

# of years employed

Hobbies / interest

Insurance Information

Policy Holder

Last

First

Middle

#SSN

Insurance Company

ID Number

Union Local Number

Insurance Address

Insurance Phone #

Policy Holder's Employer

Do You Have Dual Coverage?

Yes

If yes, please fill out the following

Policy Holder

Last

First

Middle

#SSN

Insurance Company

ID Number

Union Local Number

Insurance Address

Insurance Phone #

Policy Holder's Employer

Responsible Party Information

Name of person financially responsible for account:

Last

First

Middle

SSN#

Birth Date

Relationship to Patient

Address (Street, City, State, Zip)

Home Phone

Work Phone

Mobile Phone

Employer

Occupation

Do you have dental insurance which covers orthodontics?

Yes

Correspondence should be sent to:

Patient's Address

Financially Responsible's Address

Dental History

What is the main orthodontic problem as you see it?

Are you sensitive about the appearance of your teeth?

Are you sensitive about the appearance of any facial features? (nose, chin, lips, etc.)

What do you consider the main benefits of orthodontic treatment?

Cosmetic

Yes

Functional

Yes

Psychological/Emotional

Yes

Other

Yes

How do you feel about wearing braces?

Have you ever had an orthodontic consultation:

Yes

If yes, when?

Have you ever had braces before? If Yes, when?

Has anyone in the family received orthodontic treatment? If yes, who?

What would you like orthodontic treatment to accomplish?

Are you interested in

Metal braces

Ceramic (clear) braces

Invisialign

Name of your general dentist

Phone Number

Frequency of dental check-ups

Once/year

Twice/year

Date of last dental exam

Answer yes if applicable now or in the past:

Apprehensive about dental care

Yes

Discomfort from teeth

Yes

Previous orthodontic therapy

Yes

Teeth that are shifting

Yes

Frequent canker sores

Yes

Thumb/finger sucking as a child

Yes

Fluoride treatments

Yes

Any injuries to face, mouth, teeth

Yes

Speech therapy

Yes

Injury involving teeth

Yes

Injury to either jaw

Yes

Frequent clenching of teeth

Yes

Grinding of teeth

Yes

Wake up with sore teeth

Yes

Wake up with sore jaw

Yes

Jaw joint sounds

Yes

Jaw joint pain

Yes

Jaw tires when eating

Yes

Jaw catches when opening

Yes

Jaw locks in closed position

Yes

Jaw locks in open position

Yes

Facial pain

Yes

Frequent headaches

Yes

Neck or shoulder pain

Yes

Tonsils/Adenoids removed

Yes

Any missing permanent teeth

Yes

Any discomfort from gums

Yes

Requires premedication

Yes

Other:

If you checked yes to any of the above, please explain:

Does any genetically related family member have a similar facial/dental appearance?

Medical History

Patient's Physician

Approximate date of last exam

Are you currently in good physical health?

Yes

If no explain

Answer yes if applicable now or in the past:

Allergic to latex

Yes

Allergic to metals

Yes

Anemia/Radiation treatment

Yes

Arthritis

Yes

Asthma

Yes

Congenital heart defect

Yes

Diabetes

Yes

Ever been hospitalized

Yes

Heart attack/Stroke

Yes

Heart murmur

Yes

Hepatitis

Yes

Hormone therapy

Yes

Mouth breathing

Yes

Prolonged bleeding

Yes

Psychological counseling

Yes

Rheumatic fever

Yes

Seizures/Epilepsy

Yes

Taking medications

Yes

Tuberculosis

Yes

Drug allergies

Yes

Requires premedication

Yes

Other

If you checked yes to any of the above, please explain

Signature of Patient

Date

Office Locations

ORLAND PARK

15100 S. LaGrange Rd.,
Orland Park, Illinois 60462
ph. 708.349.1740