Information for Adult Patients Salutation * - Select One - Mr. Mrs. Ms. Dr. Patient's First & Last Name * Home Address * City * Postal Code * Email Address * Birthday * Home Phone Patient's Cell Gender * M F Are you currently pregnant Yes No Do you have any children or relatives who have had treatment in this practice? * Yes No What are their name(s)? Date Of Birth * Employer's Name * Occupation Name of Spouse Do you have dental insurance that covers orthodontic treatment? * Yes No Primary * Primary Subscriber Name * Primary Subscriber Birthdate * Primary Insurance Carrier * Primary Group Number * Primary ID Number * Primary Reimburses at % * Primary Maximum * Secondary (Please Add NA if Not Applicable) * Secondary Subscriber Name (Please Add NA if Not Applicable) * Secondary Subscriber Birthdate (Please Add NA if Not Applicable) * Secondary Insurance Carrier (Please Add NA if Not Applicable) * Secondary Group Number (Please Add NA if Not Applicable) * Secondary ID Number (Please Add NA if Not Applicable) * Secondary Reimburses at % (Please Add NA if Not Applicable) * Secondary Maximum (Please Add NA if Not Applicable) * Physician Dentist * How were you referred to our practice? Are you in perfect health? * Yes No if no please specify * Have you previously consulted another orthodontist? * Yes No Have you had any previous orthodontic treatment? * Yes No Do you want orthodontic treatment? * Yes No Indifferent Are you under the care of a physician for any reason? * Yes No If yes, please give a reason * Are you currently taking any medication? * Yes No If yes, please list * Are you in a high risk group for HIV Infection? * Yes No Allergies * Yes No If yes, please specify * Do you have a history of any serious illness? * Yes No If yes, please specify * Have you had injuries to the head? * Yes No If yes, please specify * Have you been informed of any missing or extra teeth? * Yes No Do you have a history of: Diabetes * Yes No Epilepsy * Yes No Heart Trouble * Yes No Gland or Endocrine Problems * Yes No Rheumatic Fever * Yes No Fainting or Dizziness * Yes No Bone Disorders * Yes No Nervous Disorders * Yes No Congenital Abnormalities * Yes No Emotional Disorders * Yes No Tuberculosis * Yes No Liver Problems * Yes No Blood Disorders * Yes No Hepatitis * Yes No Anemia * Yes No HIV Infection * Yes No Prolonged Bleeding * Yes No Kidney Problems * Yes No Frequent Colds * Yes No Asthma * Yes No Ear Infections * Yes No Chronic Nasal Obstruction * Yes No Mouthbreathing * Yes No Adenoid Problems * Yes No Have Adenoids been removed? * Yes No Tonsillitis * Yes No Have Tonsils been removed? * Yes No Tongue thrusting * Yes No Tooth grinding or clenching * Yes No Headaches (frequent) * Yes No Muscular soreness around head and neck * Yes No Jaw joint clicking of popping * Yes No Thumbsucking * Yes No Until what age Finger sucking * Yes No Until what age Lip biting or sucking * Yes No Until what age Have you received treatment for any of the above problems? * Yes No If yes, please specify Do you have regular dental checkups? Yes No Date of last checkup Toothbrushing After every meal Once per day Twice per day Do you floss? Yes No Reason for seeking orthodontic consultation? In accordance with Canada's federal anti-spam regulations, I accept to be contacted through email by South Surrey Smiles Yes No I hereby acknowledge that the health history provided is correct. Yes my information is correct Captcha If you are human, leave this field blank. Δ
