Adult New Patient Information

Adult Patient Information

* Patient First Name: (Required)

Patient Middle Initial:

* Patient Last Name: (Required)

Nick Name:

Home Address:

City:

State:

Zip:

Birth Date:

Age:

Gender: Male Female

Who can we thank for your referral?

Who is your General Dentist:

What is your chief concern?

Responsibile Party Information

First Name:

Middle Initial:

Last Name:

Address (if different than patient's):

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

E-mail:

How would you prefer to be contacted for appointment reminders: Text Email Both

Dental Insurance Information

Insured's Name:

Relationship to Patient:

Employer:

SS or ID#:

Birthdate:

Insurance Co:

Group Number:

Telephone:

Insured's Name:

Relationship to Patient:

Employer:

SS or ID#:

Birthdate:

Insurance Co:

Group Number:

Telephone:

Dental History

When was your last dental checkup/cleaning?

Have you ever had a negative dental experience?

Do you have any missing, impacted teeth, or extra permanent teeth?

Have you ever visited with an Orthodontist before?

Do you feel that your teeth are too small or short? Yes No

Do you feel that your teeth are too large or long? Yes No

Do you feel that your teeth are misshapen? Yes No

Do you feel that your teeth are too crooked or crowded? Yes No

Do you feel there is too much or too little gum tissue showing when you smile? Yes No

Have you ever had any pain, tenderness, or stiffness in your jaw joint (TMJ/TMD)? Yes No

Do you have any speech problems? Yes No

Have you ever had any injury to face, mouth, teeth or chin? Yes No

Airway History

Have you ever worn a CPAP for apnea issues? Yes No

Are you a restless sleeper? Yes No

Do you snore at night? Yes No

Do you sleep walk? Yes No

Are you a mouth breather? Yes No

Any isssues with bed wetting? Yes No

Do you clench/grind your teeth? Yes No

Do you sleep talk? Yes No

Have you ever worn an Oral Appliance for sleeping, snoring or apnea? Yes No

Do you have a problem concentrating either at home, school or work? Yes No

Habits

Sucking your thumb or fingers? Yes No

Lip sucking or biting? Yes No

Thrusting your tongue when swallowing? Yes No

Other oral/mouth habits? Yes No

Medical History

Do you require premedication prior to dental visits? Yes No

Are you currently takng any medications? If yes, please provide a complete list and dosage:

Have you ever taken bisphosphonate drugs use to treat osteoporosis or multiple myeloma? Yes No

Have you ever taken medications to strengthen your bones and prevent fractures? Yes No

Are you pregnant? Yes No

If yes, week #?

Other allergies not listed:

Please elaborate on any other medical concerns:

Do you have any specific questions for Dr. Matt Gaworski?

I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in strict confidence and it is my responsibility to inform this office of any changes to medical status.

I hereby authorize release of any information related to insurance claim. I consent to examination by the doctor and authorize payment of any insurance benefits.

Signature (Parent/Guardian if minor):

Date: