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Adult Registration Form

General Information

Patient’s Name:

Date of Birth:

Age: Sex:  

Address: City: Postal Code:

Home Phone: Cell:

E-mail:

Name of other family members treated by our office:

How did you hear about our office:

Dentist’s Name: Physician’s Name:

Medical History

  1. Is the patient in good general health?  
  2. Is the patient under the care of a physician for any medical concern?  
  3. Is the patient taking any medications or drugs at the present time?  
  4. Has the patient ever had any serious illness, operation, or been hospitalized?  
  5. Does the patient have or ever had any of the following?

  6. Has the patient ever experienced any unusual reactions to any of the following?

  7. For female patients: Is there a chance you may be pregnant?  
  8. Has the patient ever had any medical radiation therapy?  
  9. Is there anything else that the orthodontist should know regarding the medical history?  
  10. Has the patient had their tonsils or adenoids removed?  
  11. Has the patient ever had a severe accident involving their teeth or jaws?  

Dental and Orthodontic History

  1. Is the patient aware or concerned about their orthodontic problem?  
  2. Is the patient interested in having their orthodontic problem treated?  
  3. Has the patient ever been teased about the appearance of their teeth?  
  4. Does the patient have any difficulty chewing or swallowing?  
  5. Does the patient suffer from any jaw joint problems?  
  6. Is there a history in your family of irregular teeth?  
  7. Is there a history in your family of protruding teeth?  
  8. Is there a history in your family of congenitally missing teeth?  
  9. Is there a history of trauma to the teeth or jaws?  
  10. Does any other family member have similar appearance of their jaws?  
  11. Does any other family member have a similar arrangement of teeth?  
  12. Does the patient breath through their mouth?  
  13. Does the patient play any wind instruments?  
  14. Does the patient have or ever had habits like thumbsucking, lipsucking, lip biting, or other habits?  
  15. Has the patient had a sudden increase in height?  
  16. Has the patient seen an orthodontist previously?  
  17. Has the patient had any previous orthodontic treatment?  
  18. Has any other member of the family had orthodontic treatment?  
  19. Briefly describe the main concerns the patient has with their teeth and/or jaws?

Consent:

I have provided the above dental and medical information, reviewed it and find it accurate. If there are any changes to this history record, I will so inform this practice. I also give my authorization for an orthodontic examination to be performed. I authorize Dr. Darryl Smith to use and disclose information contained in my dental records to my dentist, family physician and other dental / medical specialist and to my insurance company and its agents / contractors with respect to myself (and / or my children’s orthodontic treatment). This information could include (but is not limited to) things such as name, address, phone number, gender, date of birth, insurance information, employer, health and / or dental records. I understand that this information is collected to provide me and my family with safe and efficient care. I also understand that this office endeavors to ensure that personal information is accurate, up to date and protected. I also acknowledge, where applicable, that it is my responsibility to inform you of any changes in my / my child’s medical status. I further acknowledge that, during the course of treatment, you will continue to discuss treatment details regarding my child with the responsible party UNLESS we choose to notify you otherwise, in writing, when my child turns 18.