Young Adult Form

TELL US ABOUT YOU:



MaleFemale



Who is responsible for making appointments?

PARENT INFORMATION


YesNo

SingleWidowedMarriedDivorcedSeparated

MOTHER's INFORMATION

FATHER's INFORMATION

Person responsible for Account



YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo


YesNoUnsureWeek


GoodFairPoor


YesNo


YesNo

For orthodontic treatment please complete the following



YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo
Tetracycline
YesNo

YesNo

HAVE YOU EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

DID/DO YOU HAVE ANY OF THE FOLLOWING HABITS?


YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo

YesNo


YesNo