Adult New Patient Form

Name

FirstLast

Prefer to be called

Home Address

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

How long at this address?

Email

Phone

Other Phone

Former Address (if less than 3 years)

Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry

Birthdate

Do you have adult orthodontic benefits?

Yes
No

Employer

Position

How long?

Work Phone

Marital Status

Spouse's Name

FirstLast

Do they have Adult orthodontic benefits?

Yes
No

Spouse's Employer

Position

How long?

Work Phone

How did you first hear about our office?

Whom may we thank for referring you to our office?

When and where are the best times to reach you?

Do you anticipate a move or transfer in the near future?

No
Yes

If so, when?

Medical Information

Overall medical health

Good
Fair
Poor

Any history of the following:

Any other medical problems we should be aware of?

Is there a tendency to:

Ear infections
Colds
Sore throats

Have tonsils and adenoids been removed?

No
Yes

If so, when?

List any drugs or medications being taken

List any allergies or drug sensitivities

Is premedication needed before dental treatment?

No
Yes

Primary Physician

Date of last visit

Dental Information:

Are you concerned about the appearance of your teeth?

Yes
No

Are you frightened or anxious about orthodontic treatment?

Yes
No

What is your main reason for seeing an orthodontist? (check all that apply)

Any other reasons?

Have you had previous treatment for

TMJ
Gum disease

If so, by whom?

Any previous orthodontic treatment?

Yes
No

When?

Is this a second opinion?

No
Yes

If so, why?

Who was the first?

Have other members of the family had orthodontic treatment? If so, whom?

Are they satisfied with the end results?

No
Yes

Do you have any speech problems?

No
Yes

If so, please explain

Any injuries to face, head, mouth or teeth?

No
Yes

If so, when?

Pain in or near ears?

No
Yes

If so, when?

Clicking or locking of jaws?

No
Yes

If so, when?

Headaches, facial pain or jaw joint problems?

No
Yes

If so, please explain

Would you mind wearing braces if necessary?

No
Yes

Invisible braces?

Yes
No

What aspects of orthodontic treatment are you most concerned with?

Are you aware of sores, lumps or irritated areas in the mouth?

No
Yes

Do you have any missing or extra teeth?

About your home care

Please rate your dental health

Good
Fair
Poor

Do you brush your teeth daily?

Yes
No

Do you floss your teeth?

Yes
No

How often?

Do you have any history of these habits?

General Dentist

Date of last visit

Any other information that would be helpful?

Agree To Terms

I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of Dr. Masri. I understand that where appropriate, credit bureau reports may be obtained.

*

Yes, I agree to the above terms & conditions.