Adult Form|McFarland Orthodontics

PATIENT INFORMATION - ADULT

Patient's Name

First Name

Last Name

Prefers to be called

Address1

Address 2

City

State

Zip

Sex

Home Phone

Area Code

Phone First 3

Phone Last 4

Business Phone

Area Code

Phone First 3

Phone Last 4

Names/Ages of Children

Are any other members of your family being treated here? If so, who?

How did you hear about Dr. McFarland?

Name of Spouse

First Name

Last Name

Business Phone

Area Code

Phone First 3

Phone Last 4

RESPONSIBLE PARTY INFORMATION

Name of person responsible for account

First Name

Last Name

Relationship to the patient:

Address1

Address 2

City

State

Zip

How long at this address?

Home Phone

Area Code

Phone First 3

Phone Last 4

Work Phone

Area Code

Phone First 3

Phone Last 4

Previous Address (if less than 3 yrs)

Number of years employed

DENTIST INFORMATION

Dentist's name

First Name

Last Name

INSURANCE INFORMATION

Are you covered by orthodontic insurance? If so, please provide following information so we can verify your coverage:

Insured's Name

First Name

Last Name

Address1

Address 2

City

State

Zip

Telephone number of insurance company

Area Code

Phone First 3

Phone Last 4

In your own words, what is the problem, or why are you here to see Dr. McFarland today?

HEALTH HISTORY

Is patient currently under physician's care? Reason:

Please check box if you now have or have had:

Adenoids removed

AIDS

Allergies

Anemia

Arthritis

Artificial heart valves

Asthma

Bone Disorders

Bruxing

Cancer treatment

Cardiac pacemaker

Congenital heart lesions

Chronic cough

Diabetes

Ear problems

Emotional problems

Endocrine problems

Epilepsy

Faintness/Dizziness

Headaches (frequent)

Heart murmur

Heart trouble

Hepatitis

Herpes

High blood pressure

HTLV-III virus

Jaundice

Joint swelling

Kidney treatment

Organ transplant

Osteoporosis

Prolonged bleeding

Psychiatric treatment

Rheumatic fever

Scoliosis

Shortness of breath

Sinus trouble

Stroke

Swelling ankles

TMJ

Thyroid problems

Tonsils removed

Tuberculosis

Venereal disease

Whiplash

Please check box if answer is YES:

Any injuries to face, mouth, teeth?

Thumb, finger, lip sucking?

Mouth-breathing when awake, asleep?

Any missing permanent teeth?

Any extra permanent teeth?

Any teeth removed by extraction?

Is there a tongue-thrust problem?

Any speech problems?

Any pain or clicking on opening mouth?

Has an orthodontist been consulted previously?

Reason if you have consulted an orthodontist previously:

TEMPORO-MANDIBULAR AND FACIAL PAIN QUESTIONNAIRE

Please choose Y or N on every item in all categories below - feel free to ask for assistance if you do not understand a question:

QUESTIONNAIRE #1

Does your jaw make noise so that it bothers you or others?

Does your jaw get stuck so that you can't open it freely?

Does it hurt when you chew or open wide to take a big bite?

Do you have earaches or pain in the front of the ears?

Do you have pain in face, cheeks, jaws, throat, or temples?

Are you unable to open your mouth as far as you want to?

Do you suffer from frequent headaches?

Does your jaw "feel tired" after a big meal or dental visit?

Are you aware of an uncomfortable or bad bite?

Are you aware that you grind your teeth at night?

Do you have the habit of "clamping" or "setting" your teeth?

Do you have any jaw symptoms or headaches upon waking each morning?

Must you chew exclusively on one side?

Have you had a blow to the jaw (trauma)?

Are you habitual gum chewer, pipesmoker, or nailbiter?

QUESTIONNAIRE #2

Does the pain or discomfort disturb your sleep?

Does the pain or discomfort interfere with your daily routine or other activities?

Do you take medication or pills for the pain or discomfort (pain relievers, muscle relaxants, or antidepressants)?

Does the pain or discomfort affect your appetite?

Do you find the pain or discomfort extremely frustrating or depressing?

Briefly describe what the pain keeps you from doing.

Do you suffer from arthritis or pain in the joints?

Do you suffer from nervous stomach or ulcers?

Do you suffer from colitis?

Do you suffer from back or neck pain (whiplash)?

Do you suffer from skin problems or allergies?

Have you ever been treated for a jaw muscle or joint disorder?

Are you "double jointed" in any of your joints?

Let's be social. Follow us: