Singortho.com

Adult Personal & Health Questionnaire
All questions in this questionnaire are strictly confidential and become a part of your medical history. Full Name:______________________________________ Sex: M or F D.O.B. _________ Age ____ SS#______-_____-_____ Home Address: (Street/City/State/Zip) ____________________________________________________________________________ Home Phone: _______________Work:_________________Mobile: ________________Email:___________________________ Marital Status: ____ (S/M/D/W) Spouse Name:___________________ Occupation:_______________________________________Employ er:______________________________________________ How did you hear about our office? __________________________________ ________________________________________________________
Medical Hist
Have you ever been treated for the below: (Check those that apply) Yes/No Yes/ No Yes/ No Yes/ No Yes/ No   Endocrine Problems   Prolonged Bleeding   Hepatitis   Diabetes   Arthritis   Nervous Disorder   Heart Problems   Cancer   Liver Problems   Asthma   Rheumatic Fever   Bone Disorder   Fainting   Birth Defects   AIDS/HIV Do you now or have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid, or Zometa? ____ If so, which drug? _____________________ Do you have any disease, condition, or problem not listed that you think we should know about? Please explain: _________________________________________________________________________________ Are you under the care of a physician? If yes why? ___________ _________________________________________ Are you taking any medication at this time? Yes  No If, yes, plea se list: _________________________________________ Do you have any allergies? Yes  No If, yes, please list:_______________________________________________________ Dental History
TMJ History
  Have there been any injuries to the face, mouth or teeth?   Do you have any problems with speech?   Do you have or have had any discomfort   Have you been informed of any missing permanent teeth?  Do you play a wind instrument? What Kind? ___________   Do you have pain or ringing in the ear?   Have you had any previous orthodontic exam or treatment?   Are any teeth sore or sensitive?   Any cavities not filled? _____________   Has the jaw ever locked or slipped out of place?   Any gum problems? ________________   Do you have frequent headaches? Your Dentist Name ______________________ Last Cleaning Date_______________________ How often do you brush? __________________ How often do you floss? ___________________ Billing Party Information (if different from above)
Name:___________________________ Relationship to Patient:____________ Sex: M or F D.O.B.:_______________ Home Address: (Street/City/State/Zip) _____________________________________________________ _____________________________________________ Home Phone:_____________________ Work Phone:__________ ________ Mobile:______________________________ SSN:_______-_____-________ Email:______________________ ____________________________________________ Marital Status:____________Spouse:______________________ _____________________________________________ Employer: ___________________ Occupation: ______________ __________No. of yrs Employed:__________________ Insurance Infor
Policy Holders Name:__________________________________ SSN: ____-___-______ Birth Date:_______________ Insurance Company: _________________________Policy ID#:_____________________ Group#:_________________ Insurance Company Address:__________________________________________________ Phone:________________ ___________________ Employer Address:_____________________________________________________ Relationship to patient:____________________________________________________________________________ I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform the office of any cha nges to child’s medical status. If this office accepts insurance, I understand that I am responsible for payment of any co-payment or deductibles or any fee that my insurance does not cover. Signature of Patient____________________________________________Date___________________

Source: http://www.singortho.com/sites/default/files/Adult%20Questionnaire_0.pdf