Medical History - Adult
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We would like to welcome you to our office.  In an effort to provide the best service possible, we ask you to fill out this form as completely as possible.  Thank you for your cooperation.
Patient Information
Patient's name
Title
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Date of Birth
MM
/
DD
/
YYYY
Gender
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Marital status
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Street Address, City, Postal code
Home phone
Cell Phone
Email
General Information
Occupation
Employer
General Dentist
Last visit to the dentist (months)
Who may we thank for referring you?
Spouse/Additional contact
Full Name and title
Address if different than above
Marital status
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Best phone number to be reached
Email
Medical History
Are you currently under the care of a phyisician? *
Physician's name and contact information
Are you pregnant? *
What are the main concerns you would like orthodontics to accomplish? *
Have you ever been evaluated for orthodontic treatment? *
Do you like your smile? *
If no, please explain
Do you smoke?
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Have you had their tonsils and adenoids removed? *
Have you ever experienced any jaw joint pain or discomfort (TMJ//TMD?) *
Do you have any extra or missing permanent teeth? *
Required
Have you ever had an injury to *
Required
Does the patient have any speech problems *
Do your gums bleed?
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Are you allergic to *
Required
If other, please explain
Do/you or have you ever had any of the following habits *
Required
Have you now or have you ever had any of the following *
Required
If yes to any of the above please elaborate
List any medical conditions not listed above
Are you currently taking any medication *
Please list any medication
I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this office of any changes in my medical status.I hereby authorize the release of any information related to my case to my dentist or primary care physician and related to insurance claims. I consent to the examination by the doctor and authorize the taking of photographs and relevant radiographs if required.
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This form was created inside of Midtown Orthodontics.