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Adult New Patient Form – Dublin Office

Sex *
MaleFemale

Previous Address (if less than 3 yrs)

Own or Rent? *
OwnRent
Date Of Birth *
Married Status *
MarriedPartneredWidowedDivorcedSeparatedSingle

Is Spouse Employed? *

YesNo

Orthodontic Insurance Information

Do you have dental insurance? *

YesNo

Do you have dual insurance coverage? *

YesNo

Person Responsible for Account

Medical History

Physician

Date of last visit

Please Check Yes or No (if Yes, please fill in details)

Are you taking any medication?*

YesNo

Are you allergic to any medication? *

YesNo

Do you have a history of a major illness?*

YesNo

Have you seen a physician in the last 12 months? *

YesNo

Are you pregnant? *

YesNo

Are there any medical conditions not listed above that we should be aware of?

Check any of the medical conditions below that the patient has had or currently has.

Abnormal bleeding/Hemophilia
Anemia
Arthritis
Asthma or Hayfever
Bone Disorders
Congenital Heart Disease
Diabetes
Dizziness
Epilepsy
Gastrointestinal Disorders
Heart Problems
Heart Murmur
Hepatitis/Liver Problems
Herpes
HIV/AIDS
Kidney Problems
Nervous Disorders
Pneumonia
Prolonged Bleeding
Radiation/Chemotherapy
Rheumatic Fever
Tuberculosis
Tumor or Cancer

Dental History

General Dentist*

Date of last visit*

What concerns you about your teeth?*

Please Check Yes or No (if Yes, please fill in details)

Are you presently in any dental pain?*

YesNo

Ever experienced any unfavorable reaction to dentistry? *

YesNo

Have you ever lost or chipped any teeth? *

YesNo

Have there been any injuries to face, mouth or teeth? *

YesNo

Is any part of the mouth sensitive to temperature? *

YesNo

Is any part of the mouth sensitive to pressure? *

YesNo

Do your gums bleed when brushing? *

YesNo

Do you have any type of thumb or tongue habit? *

YesNo

Are you a mouth breather?*

YesNo

Have you ever seen an orthodontist? *

YesNo

What is your attitude toward receiving orthodontic treatment?*

Has anyone in the family received orthodontic treatment? *

YesNo

Do your teeth or jaws ever feel uncomfortable first thing in the morning? *

YesNo

Experience any jaw clicking or popping? *

YesNo

Are you aware of clenching your teeth during the day? *

YesNo

Have you ever been told that you grind your teeth? *

YesNo

Do you have tension headaches? *

YesNo

Have you ever experienced chronic ringing in the ears? *

YesNo

Are you aware that some appointments will be during work hours?*

YesNo

Benefits

Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general good dental health. Teeth, gums and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I have truthfully answered all the above questions, and agree to inform the office of any changes in my medical or dental history. In addition, I authorize Dr. Hutta or Dr. Cook to perform a complete orthodontic evaluation.

Full Name *

Date*

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