Microsoft word - adult_acquantaince_card.doc


Orthodontic Acquaintance Card Date _____________
Patient’s Name_________________________ Birthdate ____________________Age ____________
Address __________________________________________________________________________
Home Phone_______________Height______Weight ______ Referred by _____________________
Cell Phone________________ Email___________________________________________________
Patient’s Dentist ___________________________ Patient’s Physcian ________________________
Spouse’s Name ___________________________ Home Phone ____________________________
Person Responsible for Financial Obligation _______________________ SS# _________________
Employer ________________________________ Address ________________________________
Occupation ______________________________ Telephone _______________________________
Is your orthodontic treatment covered in part by Insurance?______ Ins. Co.____________________
Address _________________________________________ Phone __________________________
Dental
Date of last check up ____________ Any facial or Dental injuries?__________________________
Please describe ____________________________________________________________________
Any baby or permanent teeth removed by your dentist ? ___________________________________
Any thumb or finger sucking habit ?_________ Until what age ? __________________________
Any difficulty breathing through the nose (awake or asleep)? _______________________________
Any tooth clenching and/or grinding ? _________ Any clicking or pain when opening or closing the
mouth? ___________________________ Any speech problems?____________________________
Do you smoke?________________________How long?___________________________________
Medical
Are you currently under the care of a physician? _____________ If so, Why? ___________________
Are you taking any medication now? _________________ If so, What? _______________________
Are you currently taking or have been given intravenous bisphosphonates for serious bone cancers, such
as Zometa or Aredia? Yes or No
Are you currently taking or have been given oral or intravenous bisphosphonates for osteoporosis,
osteopenia, or other uses, such as Fosamax, Actonel, Boniva, Reclast, Skelid, Didronel or Bonefos?
Yes or No
Any allergies or drug sensitivity? _____________________ If so, What?_______________________
Have tonsils and /or adenoids been removed ?___________ What age? ________ Please describe any
Present or past medical problem ________________________________________________________
Hospitalization and operations _________________________________________________________
General
What concerns you most about your teeth and facial appearance? _____________________________
__________________________________________________________________________________
Have other family members had orthodontic treatment? _____ In our office? ____________________
Name _________________________
Does anyone in your family have a similar dental problem?____________________________________
Do you have children?________
Your children’s names and date of birth____________________________________________________
____________________________________________________________________________________
Signature __________________________________
E-Mail Address _________________________________________________

Source: http://www.dietrichorthodontics.com/Portals/0/forms/adult-acquaintance.pdf

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