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858.487.0173 15525 Pomerado Rd. Ste. C4
Poway, CA 92064-2426 info@alignorthosd.com
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Dr. Nguyen is a graduate of the University of Montreal. She completed her general practice residency at Kingsbrook Jewish Medical Center...

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:

/ /
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.
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858.487.0173 Dr. Nguyen 15525 Pomerado Rd, Ste. C4
Poway, CA 92064-2426 info@alignorthosd.com

Serving All of San Diego:

We are pleased to serve orthodontic patients from all over San Diego, CA Including: Poway, Rancho Bernardo, Scripps Ranch, Ramona, Carmel Mountain Ranch, Rancho Penasquitos and 4S Ranch.

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Contact Us

Align Orthodontics 15525 Pomerado Rd, Ste. C4
Poway, CA 92064-2426 858.487.0173 info@alignorthosd.com

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