• Medical Dental History Form for Adult Patients

  • PATIENT

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  • CLOSEST RELATIVE


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  • DENTIST

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  • Other dentist/dental specialist now being seen:

  • PHYSICIAN

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  • Other physician/health care provider being seen now:

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

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  • DENTAL INSURANCE

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  • Your answers to the following questions are for our office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions choose yes, no, or dk/u (don't know/understand).

  • MEDICAL HISTORY

    Now or in the past, have you had:
  • Have you had allergies or reactions to any of the following:

  • DENTAL HISTORY

    Now or in the past have you had:
  • PATIENT HEALTH INFORMATION

  • List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

  • FAMILY MEDICAL HISTORY

  • If your parents or siblings ever had any of the following health problems, please explain.

  • RELEASE AND WAIVER

  • By signing below:

    I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. 

    I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

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