Adult Orthodontic Aquaintance Form
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1ADULT ORTHODONTIC AQUAINTANCE FORM
Date __________________
Demographic Information
Name __________________________________________
Name you would like to be called ________________________
Age ______ Birth date _________________ Social Security Number _____________________________ Sex (Circle one) F
M
Address _________________________________________________________________________________________________
Street
City
State
Zip Code
Phone Number #1 ___________________ (Work Cell Home)
Phone Number #2 ___________________ (Work Cell Home)
Employer ________________________________________
Marital Status: Married Single Divorced
Other ____________
Physician’s Name_____________________________________ Phone # ________________ Date of last exam _______________
Dentist’s Name ______________________________________ Phone # ________________ Date of last exam _______________
Do you have children in our practice?
No
Yes, names: ____________________________________________________
Whom may we thank for referring you to us? _____________________________________________________________________
Please provide your email address for appointment confirmation _______________________________________________
Health History
YES
NO
___
___
Do you have any current health problems? Please explain____________________________________________
___
___
Do you have a history of a major illness? _________________________________________________________
___
___
Have you ever been hospitalized? Please give reason and dates_______________________________________
___
___
Do you smoke or chew tobacco? ________________________________________________________________
___
___
Are you allergic to anything? ___________________________________________________________________
___
___
Female Patients: Are you pregnant?
___
___
Are you currently taking any medications? Please list: _______________________ ________________________
Please check any of the medical conditions below that you currently have or have been treated for in the past:
___ Abnormal Bleeding/Hemophilia ___ Diabetes
___ Hepatitis/Liver Disease
___ Pneumonia
___ Anemia
___ Dizziness
___ Herpes
___ Prolonged Bleeding
___ Arthritis
___ Epilepsy
___ High Blood Pressure
___ Radiation/Chemotherapy
___ Asthma or Hay Fever
___ Gastrointestinal Disorders
___ HIV / Aids
___ Rheumatic Fever
___ Bone Disorders
___ Heart Problems
___ Kidney problems
___ Tuberculosis
___ Congenital Heart Defect
___ Heart Murmur
___ Nervous Disorders
___ Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of?______________________________
_________________________________________________________________________________________________________
Reason for orthodontic consultation? ________________________________________________________________________
Dental History
YES
NO
___
___
Did you have braces as a child or teenager? ______________________________________________________
___
___
Has an orthodontist been consulted previously? Name ______________________________________________
___
___
Have you been informed of any missing or extra permanent teeth? _____________________________________
___
___
Have you ever had any injuries to your face, mouth, or teeth? _________________________________________
___
___
Do you have pain with chewing, yawning or wide opening? ___________________________________________
___
___
Does your jaw make noise and is pain associated with the sounds? ____________________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I understand that it is my responsibility to inform this office of any changes in my medical or dental status. I authorize Dr.
Christensen, his associates and the dental staff of Durham PDO to perform any necessary dental services that are needed
during diagnosis and treatment, including orthodontic records (models, photographs, and radiographs.) I understand that
these records may be used for both diagnostic and educational purposes.
Signature ___________________________________ Relationship to patient _________________ Date_____________
DURHAM PEDIATRIC DENTISTRY & ORTHODONTICS
121 W. Woodcroft Parkway, Durham, NC 27713 ~ Phone (919) 489-1543 ~ FAX (919) 489-2892 ~
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