Orthodontist Providence RI Metro : Tollgate Orthodontics : Alan C Smith, DDS, MSD - treating children and adults with traditional and clear braces

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PATIENT INFORMATION

Patients Name

Last

First

Middle

Address	Street
	City	State	Zip

Home Phone	Birth date	S.S.N.

If patient is a minor, give parent's or guardian's name.
Whom may we thank for referring you to our office ?

RESPONSIBLE PARTY INFORMATION

Name			Marital Status
Last	First	Middle
Residence	Street
Residence	City	State	Zip
Mailing Address	Street
Mailing Address	City	State	Zip
How long at this address	Home Phone	Work Phone

Previous Address (if less than 3 years )	Street
Previous Address (if less than 3 years )	City	State	Zip
Social Security #	Birth date	Relationship to Patient

Employer	Occupation	Number Years Employed

Spouse's Name			Relationship to Patient
Last	First	Middle

Employer	Occupation	Number Years Employed

Social Security #	Birth Date	Work Phone

INSURANCE INFORMATION

Insured's Name	Insured's Social Security #

Insurance Company	Group Number	Local Number

Insurance Company Address

Insurance Phone Number

Do you have dual coverage ?

Yes No

Insured's Name	Insured's Social security #

Insurance Company	Group Number	Local Number

Insurance Company Address

Insurance Company Phone Number

Insured's Employer

EMERGENCY INFORMATION

Name of nearest relative not living with you
Complete Address
Phone Number

PATIENT DENTAL HISTORY

What are the main concerns that you would like orthodontics to accomplish ?

YES

Have you ever been evaluated for orthodontic treatment ?

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD ) ?

Do you like your smile ?

Do your gums ever bleed ?

Do you have any speech problems ?
If yes, explain

Do you generally breathe through your mouth while awake ?

Do you generally breathe through your mouth while asleep ?

Have there been any injuries to the face, mouth teeth or chin ?

Do you have missing or extra permanent teeth ?

Have adenoids or tonsils been removed ?

Are you pregnant ?
Week Number

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

YES

Aspirin

Any Metals / Plastics

Codeine

Dental Anesthetics

Erythromycin

Latex

Penicillin

Tetracycline

Other

Please list any other drugs that you are allergic to :
Do you have an E-Mail address ?

Have you ever had any of the following diseases or medical problems ?
YES	NO		YES	NO
		Abnormal Bleeding			Heart Attack / Stroke
		Allergies to any drugs			Heart Murmur
		Anemia / Radiation Treatment			Heart Surgery / Pacemaker
		Any Hospital stays			Hemophilia / Abnormal Bleeding
		Any Operations			Hepatitis
		Artificial Bones / Joints			High / Low Blood Pressure
		Artificial Valves			HIV+ / AIDS
		Asthma / Arthritis			Hospitalized for any reason
		Blood Transfusion			Kidney Problems
		Cancer / Chemotherapy			Mitral Valve Prolapse
		Congenital Heart Defect			Psychiatric Problems
		Diabetes / Tuberculosis (TB)			Rheumatic / Scarlet Fever
		Difficulty Breathing			Severe / Frequent Headaches
		Drug / Alcohol Abuse			Shingles
		Emphysema / Glaucoma			Sinus Problems
		Epilepsy / Seizures / Fainting Spells			Tuberculosis (TB)
		Fever Blisters / Herpes			Ulcers / Colitis
		Handicaps / Disabilities			Venereal Disease
		Hearing Impairment
Please list any serious medical conditions that you have ever had :
If patient is a child does/did your child have any of the following habits ?
YES	NO		YES	NO
		Clenching / Grinding Teeth			Nursing Bottle Habits
		Lip Sucking / Biting			Speech Problems
		Mouth Breather			Thumb / Finger Sucking
		Nail Biting			Tongue Thrust

School
Hobbies
List Brothers & Sisters and Ages

General Dentist
Date of Last Visit
Family Physician
Phone Number
Date of Last Visit
Are you under the care of a physician ?	Yes No
Please Explain
Are you taking any prescription / over the counter drugs ?	Yes No
Please list each one

To Schedule a Complimentary Examination Click Here

Serving the Providence, Rhode Island metro area
500 Tollgate Road, Warwick, RI 02886 � 401.739.3900 fax 401.739.8626
www.TollgateOrthodontics.com

STATE OF THE ART CARE

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