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A B C Sam H. Arazie, D.M.D., M.S.D., P.A. Welcome to Our Office Adult Orthodontic Acquaintance Card Date___________ 20____ Patient’s name_________________________________________________ Age______ Sex: Male □ Female □ First Middle Last Name Patient Prefers to be called_________________________________________________________________ Address__________________________________________________________Home Phone________________ Street City State Zip Cell Phone__________________ Martial Status: Married □ Single □ Divorced □ Social Security No.___________________________ Occupation___________________________________Employer________________________________________ Business Address ____________________________________________Work Phone_______________________ Spouse’s Name_______________________________________________________________________________ Occupation______________________________________Employer_______________________________ Business Address__________________________________________Work Phone __________________________ Name of Person Responsible for Account if other than yourself__________________________________________ Do you have dental insurance that covers orthodontic treatment? Yes □ No □ Dentist____________________________________________ Physician_________________________________ Last visit to Dentist____________________________________________________________________________ Is there someone other than your dentist that we may thank for referring you to our office? (friends, neighbors, patients, etc.?)_____________________________________________________________ MEDICAL HISTORY Are you in good health? Yes □ No □ History of Major Illness? Are you presently under the care of a physician for a specific problem? Yes □ No □ Yes □ No □ If so, please explain__________________________________________________________________________ PLEASE CIRCLE ANY OF THE FOLLOWING CONDITIONS THAT YOU HAVE HAD OR CURRENTLY HAVE Abnormal bleeding/Hemophilia Anemia Arthritis Asthma or Hay Fever Bone Disorders Congenital Heart Defect Diabetes Dizziness 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 or Cancer Are there any medical conditions we have not discussed that you feel we should be aware of? _________________________ ____________________________________________________________________________________________________ List Any Medicines Now Being Taken. Give Reasons._________________________________________________________ ____________________________________________________________________________________________________ List Any Allergies or Drug Sensitivities._____________________________________________________________________ ____________________________________________________________________________________________________ DENTAL HISTORY Have you ever had gum disease? ____________________________________________________ Yes □ No □ Has an orthodontist been consulted previously?_________________________________________ Yes □ No □ Have you had any previous orthodontic treatment?_______________________________________ Yes □ No □ If so, by whom?___________________________________________________________________ Do you have an unusual amount of stress in your life?____________________________________ Yes □ No □ Reason for seeking orthodontic treatment; What problem do you wish to have corrected? ____________________ ___________________________________________________________________________________________ Please list any additional information which you feel might be helpful.____________________________________ ___________________________________________________________________________________________ THANK YOU Patient’s Signature: ______________________________________Date: ____________________ Member
