Longmontbraces.com

Welcome to Longmont Braces!
Please fill out this form completely. Thank you! About You
Name_________________________________ Preferred Name/Nickname_______________________________________________
Street Address_______________________________________________________________________________________________
City______________________ State ___________ Zip __________________Home Phone__________________________________
Birth Date____/____/____ Age________ Sex M F Employer_____________________________________________________
Day-Time Phone ______________Cell Phone ______________E-mail address ______________Spouse’s Name________________
How did you hear about our office? _______________________________________________________________________________
What is the reason you are seeking an orthodontic evaluation? _________________________________________________________
Has an orthodontist been consulted previously? Yes No Reason: _______________________________________________
Please list other family members seen in our office and their relation to you: _______________________________________________
Medical Health Information
Have you been hospitalized for any surgical procedure or serious illness? Yes No
Name of your physician_________________________________________________________________________________________
Address_________________________________________________________________Phone_______________________________
Do you have or have you had any of the following diseases or conditions? (Check all that apply.)______________________________
Yes No
Heart Defect, Heart Murmur, Heart Disease Do you or have you ever taken bisphosphonates, including Fosomax, Didronel, Boniva, Aredia, Actonel, Skelid, or Zometa?________
If so, which drug?________________________
Do you have any disease, condition, or problem not listed that you think we should know about? Please Explain:
___________________________________________________________________________________________________________
Are you taking any medication at this time? Yes No If yes, Please list_____________________________________________
Dental Insurance Information
Primary Insurance Company Name______________________________________________________________________________
Do you participate in a flex plan? Yes No

Dental Health Information
Are you experiencing any Dental Problems Yes No Date of last dental visit___/___/____
How often do you brush and floss each day? Brush ___ times per day Floss ___ times per day
Dentist: _______________________________
Do you have or have you ever had any of the following problems?
Yes No
Tooth Sensitivity to Heat, Cold, or Sweets I acknowledge that the above information is correct. I will notify Longmont Braces of any changes that occur after this date. I hereby authorize Longmont Braces and its designees to perform an initial orthodontic evaluation/examination. Name:__________________________________ Date:_______________________

Source: http://www.longmontbraces.com/docs/health-history-adult.pdf