Adult New Patient Form

    Former Address (if less than 3 years)

    YesNo

    SingleMarriedDivorcedWidowedSeparated

    YesNo


    NoYes

    Medical Information

    GoodFairPoor

    NoYes

    NoYes

    Ear infectionsColdsSore throats

    AsthmaDiabetes RheumaticBone DisordersEpilepsyGlaucomaAnemiaHepatitisBlood diseaseAIDS/HIVHeart diseaseFeverAllergies

    Dental Information:

    YesNo


    YesNo

    NoYes

    YesNo

    YesNo

    NoYes

    NoYes

    YesNo

    NoYes

    NoYes

    NoYes

    NoYes


    NoYes


    NoYes

    GoodFairPoor

    YesNo

    YesNo

    QualityEstheticsCostDiscomfortTime

    Crooked teethCrowdingClose spacesCrossbiteJaw painHeadachesDon't like smileCosmeticsOverbiteBad biteHard to chewCan't close mouth

    Mouth BreathingThumb suckingNail/Lip bitingSnoringLeaning on chin or faceGrinding of teeth

    About your home care

    Agree To Terms

    I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in patient's medical status. I also authorize the dental staff to perform the necessary orthodontic services as needed. I further authorize that photos taken during treatment may be used in journal articles or promotional materials and are the property of Dr. Masri. I understand that where appropriate, credit bureau reports may be obtained.

    Yes, I agree to the above terms & conditions.