ADULT PATIENT INFORMATION
* Name: (Required)
Nickname
Sex: Female Male
Age
Birthdate
Street Address
City
State
Zip Code
* Email (Required)
Home Phone
Work Phone
Cell Phone
Occupation
Whom may we thank you referring you to our office?
Please list your hobbies/interests.
RESPONSIBLE PARTY INFORMATION
Person responsible for account
SSN
Billing address
City
State
Zip Code
Relationship to patient
Date of Birth
EMERGENCY CONTACT
Name
Relationship
Address
City
State
Zip Code
Home Phone
Work Phone
Cell Phone
The office of Dr. Brady will be happy to process your orthodontic claims.
To successfully process your claims, all of the following information is necessary.
If you do not have all of the required information we suggest you contact your Human Resources Representative and they can help you with any missing information.
DENTAL INSURANCE INFORMATION
Primary Insured's Name
Insured's Date of Birth
Insured's SSN
Insurance ID#
Insured's Phone Number
Insurance Company
Insurance Co. Full Address
Insured's Employer
Group No.
DUAL INSURANCE INFORMATION (if applicable)
Secondary Insured's Name
Insured's Date of Birth
Insured's SSN
Insured's ID#
Insured's Phone Number
Insurance Company
Insurance Co. Full Address
Insured's Employer
Group No.
MEDICAL HISTORY
Physician
Phone
Physician's Address
City
State
Zip Code
General Health and Known Illnesses
Present Medications
Surgeries (with approximate dates)
Is there a possibility that you may be pregnant? Yes No
Have you ever had an allergic reaction to medication? Yes No
If Yes, please list the medication(s)
Have you ever had an allergic reaction to foods; latex; any metals, especiallyNickel or Titanium , or any other substance? Yes No
If Yes, please list your allergy(ies) to any of the above mentioned
Have you ever had any of the following:
Bleeding History: Yes No
Cancer: Yes No
Diabetes: Yes No
Hearing Loss: Yes No
Epilepsy: Yes No
Liver Problems: Yes No
High Blood Pressure: Yes No
Migraine Headaches: Yes No
Stomach Ulcers: Yes No
Hepatitis: Yes No
Kidney Problems: Yes No
AIDS or other immune system disorder: Yes No
Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion arteriosclerosis, stroke): Yes No
Damaged heart valves (Mitral valve prolapse, artificial heart valve, heart murmur) or any other conditions which may require you to be premedicated: Yes No
If yes to any of the above, does your condition require you to be premedicated?
DENTAL HISTORY
Patient's Dentist
Date of Last Visit (approx.)
Dentist's Address
City
State
Zip Code
Have you previously consulted an orthodontist? Yes No
If yes, when and with whom?
Have you consulted any other dental specialty? Yes No
If yes, when and with whom?
Is there a history of congenitally missing teeth? Yes No
Patient Relative(s)
Do your gums bleed when you brush your teeth? Yes No
Is any part of your mouth sensitive to temperature? Yes No
Is any part of your mouth sensitive to pressure? Yes No
Have you ever sucked your thumb or finger(s)? Yes No
If so, have you stopped this habit? Yes No
Do you breathe predominantly through your mouth? Yes No
Have you had your tonsils/adenoids removed? Yes No
If Yes, when?
Do you clench or grind your teeth during the day? Yes No
Have you been made aware of clenching or grinding your teeth during the night? Yes No
Do you now have, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)? Yes No
Have you ever had clicking or popping in your jaw joint? Yes No
If Yes, please explain.
Have you ever experienced pain when opening wide? Yes No
Have you had injury to your jaw? Yes No
If Yes, please explain.
Have you had any injury to your teeth? Yes No
If Yes, please explain.
