Align Orthodontics > About Us > Adult Patient Form Please check the required fields First Name: Last Name: DENTAL (Check all that apply) Are you presently experiencing dental discomfort/pain? Have you ever experienced an unfavorable reaction to dentistry? Have you been informed of extra/missing teeth? Is any part of your mouth sensitive to temperature/pressure? Do your gums bleed when you brush? Do you smoke/use tobacco products in any form? Have you ever had any pain, tenderness, clicking, or popping in your jaw (TMJ/TMD)? Do you clench/grind your teeth? Do you have any difficulty chewing / swallowing food? Does your bite feel uncomfortable? Have you previously consulted an orthodontist? Are you aware of any dental work that needs to be completed prior to orthodontic treatment? Date of your most recent dental examination: -MM- 01 02 03 04 05 06 07 08 09 10 11 12 / -DD- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / -YYYY- 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 Have there been any injuries to your face, mouth, teeth or chin? If yes, please explain: Have any teeth been removed by extraction? If yes, please explain: Has anyone else in your family received orthodontic treatment? If yes, how did they feel about the results? MEDICAL - Have you ever had any of the following diseases or medical conditions? (Check all that apply) Abnormal Bleeding/Hemophilia Anemia Arthritis Asthma/Hayfever Blood Disorders Bone Disorders Congenital Heart Defect Depression/Mental Illness Diabetes Dizziness Endocrine Problems Epilepsy Gastrointestinal Disorders Heart Problems Heart Murmur Hepatitis/Liver Problems Herpes High Blood Pressure HIV+/AIDS Kidney Problems Nervous Disorders Pneumonia Prolonged Bleeding Radiation/Chemotherapy Rheumatic Fever Tuberculosis Tumor/Cancer Do you have any other medical condition not described above? If yes, please explain: Female Patients Are you pregnant? Week #: Have you had an allergic reaction to any of the following? (Check all that apply) Aspirin Codeine Dental Anesthetics Erythromycin Latex Penicillin Tetracycline Metals Others Please list any other medications to which you have had an allergic reaction: Please list all medications that you are currently taking: Are you currently under the care of a physician? If yes, please explain: Please explain any medical problems that you have had in the past: I have read and I understand the above questions. I will not hold Dr. Henry or any member of his staff responsible for any errors or omissions that have been made in the completion of this form. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any later changes to the history record or medical/dental status. We will discuss your treatment with person(s) financially responsible for your account and referring doctors/dentists. Signature Date 12 01 02 03 04 05 06 07 08 09 10 11 / 21 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 / 2024 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 Security Code: * Reload Image :: PHP FormMail Generator ::