Adult History Form - Scott Family Orthodontics

Patient's Name

First

Middle

Last

Name Patient Goes By

Birthdate

Age

Sex

Home Address

Home Phone

Patient's Interests: Sports, Hobbies, Music, Church

SS#

Employed By

Work Phone

Patient's Dentist

Patient's Physician

Refferred By

Close Friend or Relative Who is a Patient in this Office

Person Responsible for Account (Name)

If You Are Covered by Dental Insurance that Provides for Orthodontic Treatment, Please Complete The Following:

Insured's name

Relationship to Patient

Insured's SS#

Insured's Date of Birth

Insured is Employed with

Insurance Company Name

Insurance Company Address

Insurance Company Phone #

Insured's ID #

Group # (Plan, Local or Policy #)

Spouse

Name

First

Middle

Last

Address

Home Phone

SS#

Date of Birth

Employed By

Work Phone

Medical History

Is the patient in good health?

Is the patient under physician's care?

If so, for what reason

Are there any impending operations?

If so, please describe

Is the patient taking prescription medications?

If so, please list

Is the patient allergic to medicines?

If so, please list

Does patient use tobacco

If so and within the last 2 years, when?

Does patient take herbal medicines?

If so, please list

For Females Only:

Is the patient presently pregnant?

Does the patient take birth control pills?

Has patient had or currently have any of the following:

Aids/ Hiv+

Allergies to:

Metals

Vinyl

Latex

Acrylic

Seasonal

Other

Anemia

Arthritis

Asthma

Bone Disorders

Circulatory Problems

Convulsions

Diabetes

Endocrine or Thyroid Problems

Fainting

Frequent Headaches

Glaucoma

Heart Problems

Hepatitis

High Blood Pressure

Kidney Problems

Liver Problems

Neurological Problems

Prolonged Bleeding

Removal of Tonsils & Adenoids

Rheumatic Fever

Sinus Problems

Dental History

HAVE YOU HAD A RECENT DENTAL CHECKUP?

DO YOU BITE LIP/FINGERNAILS?

HAS THERE BEEN A BLOW OR INJURY TO FACE OR TEETH?

HAVE TEETH BEEN KNOCKED OUT OF THE MOUTH AND REIMPLANTED?

ARE THERE SPEECH PROBLEMS?

HAS TREATMENT BEEN RECEIVED FOR THESE PROBLEMS?

ARE THERE SWALLOWING PROBLEMS?

IS THERE CLICKING OR PAIN WHEN OPENING THE JAW?

HAVE YOU EVER HAD JAW JOINT (TMJ) TREATMENT?

IS THERE DIFFICULTY BREATHING THROUGH NOSE (MOUTH BREATHING)?

HAVE YOU EVER HAD SURGERY TO REPAIR CLEFT LIP AND/OR PALATE?

DO YOUR GUMS BLEED WHEN BRUSHING TEETH?

DO YOU USE DENTAL FLOSS?

DO YOU HAVE FREQUENT SORES IN THE MOUTH OR LIPS?

DO YOU PLAY A MUSICAL INSTRUMENT?

IF SO, WHICH ONE

DIETARY HABITS

DO YOU EAT BALANCED MEALS (MEAT, VEGETABLES, FRUIT, ETC.)?

DO YOU TAKE SUPPLEMENTAL VITAMINS?

IS THERE A HIGH INTAKE OF SWEETS?

IS THERE A HIGH INTAKE OF CAFFEINE?

DO YOU CHEW GUM FREQUENTLY?

DO YOU CHEW ICE, EAT LEMONS OR LIMES?

SLEEP HABITS

ARE YOU A SOUND SLEEPER?

DO YOU SLEEP WITH YOUR MOUTH OPEN?

DO YOU SNORE?

DO YOU GRIND YOUR TEETH WHILE SLEEPING?

HAVE YOU EVER BEEN TESTED FOR SLEEP APNEA?

RESULTS?

IF YOU HAVE ANY ADDITIONAL CONCERNS OR QUESTIONS YOU WISH THE DOCTOR TO BE AWARE OF, OR YOU WISH THE DOCTOR TO ANSWER, PLEASE DESCRIBE

Signature

AUTHORIZATION

THIS OFFICE RESERVES THE RIGHT TO VERIFY THE CREDIT STATUS OF POTENTIAL PATIENTS PRIOR TO EXTENDING CREDIT FOR TREATMENT FEES AND MAY, AT THE DISCRETION OF THIS OFFICE, USE THE SERVICES OF ONE OR MORE CREDIT REPORTING SERVICES. ADDITIONALLY, I HEREBY AUTHORIZE DR. SCOTT TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF INSURANCE BENEFITS, AND I ASSIGN DIRECTLY TO THE DOCTOR ALL INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I FURTHER AUTHORIZE THE USE OF THIS SIGNATURE ON ALL MY INSURANCE SUBMISSIONS, WHETHER MANUAL OR ELECTRONIC.

Signature

FACIAL AND FUNCTIONAL EXAM

SYMMETRY

Normal
Asymmetric
Facial Midlines Off (R)
Facial Midlines Off (L)

FACIAL MUSCLE BALANCE

Normal
Hyper
Hypo

RESPIRATION

Normal
Mouth Breathing

LIP TONE

Normal
Hyper
Hypo

PROFILE

Acceptable
Bimax
Maxillary Protrusion
Maxillary Protrusion (Skeletal)
Maxillary Protrusion (Dental)
Maxillary Retrusion
Maxillary Retrusion (Skeletal)
Maxillary Retrusion (Dental)
Mandibular Retrusion
Mandibular Retrusion (Skeletal)
Mandibular Retrusion (Dental)

SWALLOW

Normal
Abnormal
Tongue Thrust

UPPER LIP LENGTH

Normal
Short
Long

LOWER FACIAL HEIGHT

Normal
Deficient
Excessive

SPEECH

Normal
Abnormal

NASOLABIAL ANGLE

Normal
Acute
Obtuse

HABITS

None
Thumb
Lip
Tongue