Hoffman Orthodontics

ADULT PATIENT FORM

First Name

Last Name

Birthdate

Address

City

State

Zip Code

Country

Home Phone

Cell Phone

Referred By

Spouse

Employer

Position

Work Phone

Physician

Dentist

Billing Name

What concerns you most about your teeth?

Date of most recent dental examination:

How often do you brush?

How often do you floss?

Do you take antibiotics prior to an orthodontic appointment?

Yes

Why?

Teeth sensitive to hot or cold?

Yes

Teeth throb or ache?

Yes

Jaw fractures, facial trauma, cysts, mouth infections?

Yes

Bleeding gums, bad taste, mouth odor?

Yes

Periodontal or "gum problems?"

Yes

Frequent canker sores, cold sores?

Yes

Abnormal swallowing habit or "tongue thrusting?"

Yes

Mouth breathing habit, difficulty in breathing?

Yes

History of finger or thumb sucking?

Yes

Tooth grinding, jaw clenching, clicking or locking?

Yes

Do you experience any pain or soreness in the muscles of your face, or around your ears?

Yes

Have you ever been treated for "TMJ" problems (jaw joint or facial muscle pain)?

Yes

Difficulty chewing or opening jaw?

Yes

History of supernumerary (extra) or congenitally missing teeth?

Yes

Have any permanent teeth been removed?

Yes

Aware of loose, broken or missing fillings?

Yes

Any teeth irritating cheek, lip, tongue or palate?

Yes

Have you ever had Orthodontic treatment (braces, expander, or worn a retainer?)

Yes

Have you recently been under another dentist's or specialist's care?

Yes

For:

Have you ever had Periodontal (gum) treatment?

Yes

Concerned about spaced, crooked, protruding teeth?

Yes

Aware or concerned about under or over-developed jaws?

Yes

Any relative with similar tooth or jaw relationships?

Yes

Any wisdom tooth problems?

Yes

Have you had any serious trouble associated with any previous dental treatment?

Yes

Has anyone in the family received orthodontic treatment?

Yes

Who?

Heart murmur?

Yes

History of rheumatic fever?

Yes

Rhuematoid or arthritic conditions?

Yes

Endocrine or thyroid problems?

Yes

Kidney problems?

Yes

Diabetes?

Yes

Cancer or been treated for a tumor?

Yes

Stomach ulcer or hyperacidity?

Yes

Polio, mononucleosis, tuberculosis, pneumonia?

Yes

Problems of the immune system?

Yes

Hepatitis, jaundice or liver problem?

Yes

AIDS or HIV Positive?

Yes

Fainting spells, seizures, epilepsy or neurologic disease?

Yes

Mental health or behavrial problems?

Yes

Vision, hearing, tasting or speech difficulties?

Yes

Loss of weight recently, poor appetite?

Yes

Excessive bleeding, black and blue tendency, anemic or bleeding disorder?

Yes

High or low blood pressure?

Yes

Cardiovascular problems (heart trouble, heart attack angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects or rheumatic heart)?

Yes

Skin disorder?

Yes

Frequent headaches, colds or sore throats?

Yes

Any history of speech problems?

Yes

Eye, ear, nose or throat condition?

Yes

Hayfever, asthma, sinus trouble, hives?

Yes

Tonsil or adenoid conditions?

Yes

Are you currently taking or have you ever taken bisphosphonates or been treated for osteoporosis, osteopenia, bone disorder, or bone cancer?

Yes

Allergies or drug reactions?

Yes

Are you taking medications, nutrient supplements or non-prescription medicine?

Yes

Please name them

Are you currently being treated by a health care professional?

Yes

Who?

For?

Female Patients Only

Are you pregnant?

Yes

Due Date:

Are you taking birth control pills?

Yes

Are you anticipating getting pregnant?

Yes

Send

ADULT PATIENT FORM

Female Patients Only

CONTACT

Contact information