Adult Orthodontic Health History Form | Orthotime American Fork

Orthodontic Health History Adults

Date:

First

Middle

Last

Birth Date:

Age:

Please check one:

Male

Female

Patient’s Address:

Street Address

Address Line 2

City

State / Province

ZIP / Postal Code

Country

E-Mail Address:

Cell #:

Emergency contact name and number:

Cell #:

Employer

Employer‘s phone#

Are family members seen by us?

Yes

First

Middle

Last

First

Middle

Last

Dentist:

Phone:

Date of last exam:

INSURANCE INFORMATION

Person financially responsible for this account:

Insurance coverage for Orthodontic treatment?

Insurance Company:

Address:

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Primary Policy Holder Name:

Birth Date:

ID#

Group #

Insurance Company:

Address:

Address Line 2

City

State / Province

ZIP / Postal Code

Country

Primary Policy Holder Name:

Birth Date:

ID#

Group #

PATIENT PROFILE

Is the patient concerned with the appearance of their smile?

Why do you think orthodontic treatment is needed?

Has there been any prior orthodontic treatment or appliances?

Is there any information that would help us better treat the patient?

HEALTH HISTORY

Are you currently under the care of a physician?

YES

Please explain:

Are you taking any prescription / over – the- counter drugs?

YES

Are you pregnant?

YES

Weeks #

DENTAL HISTORY

Have there been any accidents or trauma to the teeth or face?

Are there any teeth missing?

Have any teeth been removed?

Are there any other dental conditions or problems that we should be aware of?

Have you ever had or been evaluated for orthodontic treatment

YES

Do you have any speech problems?

YES

What is your main concern that you would like orthodontics to accomplish?

I request and authorize Dr. Watson to examine, clean and provide dental treatment for my teeth. I further request and authorize the taking of dental x-rays as may be considered necessary by Dr. Watson to diagnose my dental problems. I will allow photographs to be taken of my teeth for diagnostic purposes. I understand that dental treatment includes efforts to guide behavior by helping you to understand the treatment. Signature_____________________________ Relationship to patient____________ Date_____________

20 YEARS creating timeless smiles!

Adult Health History

INSURANCE INFORMATION

PATIENT PROFILE

HEALTH HISTORY

DENTAL HISTORY

Jeremy R. Watson DDS, MS 1248 East 90 North, Suite 201, American Fork, UT 84003