Adult Patient Information Form - Guymon Orthodontics (Page 2 of 2) in pdf

Adult Patient Information Form - Guymon Orthodontics Page 2

Health History:

Is patient taking any medications?

Is patient aware of being allergic to or has ever reacted adversely to any medications?

Please check the box if you now have or have ever had:

Please check the box if the answer is YES:

Latex Allergy

Is the patient pregnant?

Tonsils or Adenoids Removed

Has the patient reached puberty?

Allergies/ Sinus Trouble

Thumb, finger, or lip sucking? (Please circle all that apply)

Artificial Heart Valves

Mouth-breathing when awake or asleep? (Please circle all that apply)

HIV Positive/ AIDS

Any injuries to the face, mouth, or teeth? (Please circle all that apply)

TMJ Problems

Any pain or popping when opening mouth?

Osteoporosis

Are you aware of an uncomfortable or bad bite?

Emotional Problems/ Psychiatric Treatment

Do you take any bisphosphate medication for osteoporosis?

Any missing or extra teeth?

Are you aware of any other disease, condition, or problem not listed above that we should know about?

Have you consulted with an orthodontist previously?

Reason:

In your own words, describe your orthodontic problem and what you would like orthodontic treatment to accomplish:

CONSENT: The undersigned hereby authorizes the doctor to take x-rays, study models, photographs to make a thorough

diagnosis of the patient’s orthodontic needs and send dentist information regarding diagnostic findings. I understand that

where appropriate, credit bureau reports may be obtained.

Signature:

Date:

Adult Patient Information Form - Guymon Orthodontics Page 2