Office Forms

Nellie Gail Orthodontics | BRACE YOURSELF FOR A BEAUTIFUL SMILE !

For your convenience, you may download and print our new patient forms below.

New Patient Form - Child

New Patient Form- Adult

New Patient Information- Adult

Today's Date: Patient's Name

MaleFemaleAge Date of Birth

Address

Home Phone Mobile Phone

Referred ByFamily Dentist

Place Of EmploymentBusiness Phone

Spouses's NameHome Phone

AddressCity Zip

Place Of EmploymentBusiness Phone

Please provide the following information if you would like our office to check with your insurance carrier for orthodontic benefits:

Name of InsuredDate of Birth SSN

Primary Ins. Co.Group # or Plan Name

Secondary Ins. Co.Group # or Plan Name

Instructions: Please answer all questions as completely and accurately as possible; your confidentiality will be respected.

What are your primary concerns that brought you to our office?

Please check any of the following that are concerns regarding the teeth and jaws:

	crowding
	receded jaw
	spaces
	jaw dysfunction
	irregularly shaped teeth
	headaches/facial pain

	overbite
	prominent jaw
	gum disease or recession
	clicking jaw
	protrusion of teeth
	other

	buckteeth
	gummy smile
	missing teeth
	mouth too small
	ringing/stuffiness of ears
	jaw pain

Do any blood relatives have similar problems? FatherMotherBrotherSisterOther

The following are also of interest to the orthodontist: Please check yes or no. Do you:

YES	NO
		snore when sleeping
		have frequent colds
		have difficulty swallowing
		have pain in the jaw joint
		have speech problems
		suck finger or thumb (ever? Y/N) If previously, age ceased
		tongue thrust

YES	NO
		breathe primarily through the mouth
		have frequent sore throat or tonsillitis
		have difficulty chewing
		have clicking in the jaw joint
		smoke
		bite or suck on lip
		grind teeth
		other habits

Dental History:

1. Dental checkups once a year twice a year only if urgent never

2. When was your last dental checkup or cleaning? Next Scheduled?

3. Has your dentist recommended any restorative work (e.g. replacement of fillings, crowns, veneers, bridges, implants, etc.)?: yes no

If yes, what has been recommended?

4. Your interest in orthodontic treatment: want treat if necessary unwilling but agrees no thanks

5. Orthodontic treatment prompted by: patient dentist spouse parentother

6. Have you ever had previous orthodontic consultation or treatment? yes no

7. Have you ever had any unusual dental experiences? yes no

If yes, please explain

Medical History

Present Health Good Fair Poor

Have you ever had any of the following conditions? Please check yes or no for each

YES	NO
		Allergies
		Autoimmune disorder
		High Blood Pressure
		Cancer
		Epilepsy
		Emotional Problems
		Kidney Disease
		Ringing In Ears

YES	NO
		Asthma
		Arteriosclerosis
		Low Blood Pressure
		Diabetes
		Endocrine Problems
		Female Problems
		HIV+
		Sleep Disturbance

YES	NO
		Blood Disease
		Heart Disease
		Bone Disorders
		Dizziness
		Hepatitis
		Hearing Disorder
		AIDS
		Trauma To Head

Medications: Current medications that you take. Please check yes or no for each.

YES	NO
		Bone Density Drugs (e.g. Fosamax, Boniva)
		Heart Pills
		Pain Pills (Codeine, Demerol, etc.)
		Diet Pills (diuretics, Phen-Fen, Redux, etc.)
		Sleeping Pills
		Other

YES	NO
		Antibiotics
		Vitamins
		Birth Control Pills
		Insulin
		Muscle Relaxants

Have you been on any medications in the past six months that you are not currently taking? Yes No
If yes, please list the medications above that the patient is not currently taking but has taken within the past six months

Allergies: You have an allergic response to

YES	NO
		Latex
		Metals
		Dairy Products/Wheat/Cereals
		Other

YES	NO
		Pain Pills
		Antibiotics
		Dyes In Food

Are there any other medical, dental, or surgical problems not covered above or any conditions an orthodontist, oral surgeon, or physician should know about? Yes No

If yes, please explain below

Signature Of Person Filling Out Form Date