Adult Intake Form

Please complete the orthodontic intake questions below

1. About You

Today's Date

First Name

Last Name

Birthdate

Gender

Male Female

Street Address

Street Address Line 2

City

State

Zip Code

Best Phone Number

2. Referral and Dentist

Whom may we thank for referring you?

General Dentist

Last Dental Visit

3. Orthodontic Insurance

Do you have orthodontic coverage?

Yes No

Insurance Company Name

Group #

Policy #

Policy Owner's First Name

Policy Owner's Last Name

Relationship to Patient

Policy Owner's Birthdate

4. Medical and Dental History

What are your concerns regarding your teeth?

Have you previously had orthodontic treatment?

Yes No

If yes, when?

Have you ever had any problems with your jaw (TMJ)?

Yes No

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

Yes No

Have you ever had permanent teeth removed?

Yes No

Do you breathe through your mouth?

Yes No

Are you currently under a physician's care?

Yes No

Your Physician

Physician Phone

Please describe your general health

Good Fair Poor

Please list all medications you are currently taking

Please list any medical conditions you have

Allergies (check all that apply)

Penicillin Aspirin Latex Metals Local Anesthesia Other None

Have you ever had any of the following medical problems?

AIDS/HIV Anemia Arthritis Asthma Blood Disease Cancer Diabetes Epilepsy Fainting Heart Disease Heart Murmur Hepatitis High Blood Pressure Kidney Disease Liver Disease Rheumatic Fever Seizures Stroke Thyroid Problems Tuberculosis

Please discuss any conditions checked above

Have you ever experienced any of the following?

Thumb/Finger Sucking Tongue Thrust Nail Biting Teeth Grinding Jaw Clicking Difficulty Chewing Lip/Cheek Biting

Emergency Contact Name

Emergency Contact Phone

5. Consult Questions

Has the patient already seen a general dentist, or do they need to see one first?

Already referred by general dentist Needs to see general dentist first

Are there any cavities or unfinished dental work still needing treatment?

Yes No

What kind of scheduling works best?

Weekdays are okay Weekdays only Saturday only

Does the patient have any sensitivity, habits, or concerns we should know about?

Are you interested in aligners or comparing braces and aligners?

Braces only Aligners only Compare both Not sure