Adult Medical Dental History

Medical Dental History Form for Adult Patients
PATIENT
Today's Date*

MonthDayYear
Date
Title*

Mr.Mrs.Ms.MissDr.Other
Patient's Name*

First nameMiddle initialPatient's Last name
I prefer to be called
Birth date*

MonthDayYear
Date
Sex*

MaleFemale
Social Security #
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Address*

Home address

Street Address Line 2

City, State, Zip codeState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone *

Area CodePhone Number
Email address*
example@example.com
Occupation
Employer
CLOSEST RELATIVE
Title*

Mr.Mrs.Ms.MissDr.Other
Spouse or closest relative's name(s)*
First and Last Name
Relationship to patient*
Cell Phone Number*

Area CodePhone Number
DENTIST
Patient's General Dentist*
City, State*
Last Seen*

MonthDayYear
Date
Reason*
Other dentist/dental specialist now being seen:
Name
City, State
Reason
PHYSICIAN
Patient's General Physician*
City, State*
Most Recent Physical Exam*

MonthDayYear
Date
Other physician/health care provider being seen now:
Name
City, State
Reason
GENERAL INFORMATION
What concerns you about your teeth?*
Who suggested that you might need orthodontic treatment?*
Why did you select our office?*
Have you had any previous orthodontic treatment? Please describe*
Hava any other family members been treated in this office? Please name them.*
Do you think that any of your work or leisure activities affect your teeth or jaws?*
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?*
First and Last Name OR Self
Social Security #*
Address*

Home Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
Home Phone

Area CodePhone Number
Email address:*
DENTAL INSURANCE
Primary policy holder's full name
Birthdate

MonthDayYear
Date
Social Security #
Relationship to Patient
Address and phone (if not listed above)
Insurance Company
ID/Member #
Group #
Secondary policy holder's full name
Birthdate

MonthDayYear
Date
Social Security #
Relationship to patient
Address and phone (if not listed above)
Insurance company
ID/Member #
Group #
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:
Birth defects or hereditary problems?*

yesnodk/u
Bone fractures, or major injuries?*

yesnodk/u
Any injuries to face, head, neck?*

yesnodk/u
Arthritis or joint problems?*

yesnodk/u
Endocrine or thyroid problems?*

yesnodk/u
Diabetes or low sugar?*

yesnodk/u
Kidney problems?*

yesnodk/u
Cancer, tumor, radiation treatment or chemotherapy?*

yesnodk/u
Stomach ulcer, hyperacidity, acid reflux?*

yesnodk/u
Immune system problems?*

yesnodk/u
History of osteoporosis?*

yesnodk/u
Gonorrhea, syphilis, herpes, sexually transmitted diseases?*

yesnodk/u
AIDS or HIV positive?*

yesnodk/u
Hepatitis, jaundice, or other liver problem?*

yesnodk/u
Polio, mononucleosis, tuberculosis, pneumonia?*

yesnodk/u
Seizures, fainting spells, neurologic problems?*

yesnodk/u
Mental health disturbance or depression?*

yesnodk/u
Vision, hearing, or speech problems?*

yesnodk/u
History of eating disorder (anorexia, bulimia)?*

yesnodk/u
High or low blood pressure?*

yesnodk/u
Excessive bleeding or bruising, anemia?*

yesnodk/u
Chest pain, shortness of breath, tire easilt, swollen ankles?*

yesnodk/u
Heart defects, heart murmur, rheumatic heart disease?*

yesnodk/u
Angina, arteriosclerosis, stroke, or heart attack?*

yesnodk/u
Skin disorder (other than common acne)?*

yesnodk/u
Do you eat a well-balanced diet?*

yesnodk/u
Frequent headaches or migraines?*

yesnodk/u
Frequent ear infections, colds, throat infections?*

yesnodk/u
Asthma, sinus problems, hayfever?*

yesnodk/u
Tonsil or adenoid condition?*

yesnodk/u
Do you frequently breathe through your mouth?*

yesnodk/u
Have you had allergies or reactions to any of the following:
Local anesthetics (novocaine, lidocaine, xylocaine)?*

yesnodk/u
Latex (gloves, balloons)?*

yesnodk/u
Aspirin?*

yesnodk/u
Ibuprofen (Motrin, Advil)?*

yesnodk/u
Penicillin?*

yesnodk/u
Other antibiotics?*

yesnodk/u
Metals (jewelry, clothing snaps)?*

yesnodk/u
Acrylics?*

yesnodk/u
Plant pollens?*

yesnodk/u
Animals?*

yesnodk/u
Foods?*

yesnodk/u
Other substances?*

yesnodk/u
DENTAL HISTORY

Now or in the past have you had:
Permanent or extra (supernumerary) teeth removed?*

yesnodk/u
Supernumerary (extra) or congenitally missing teeth?*

yesnodk/u
Chipped or injured primary or permanent teeth?*

yesnodk/u
Any sensitive or sore teeth?*

yesnodk/u
Bleeding gums, bad taste or mouth odor?*

yesnodk/u
Jaw fractures, cysts, infections?*

yesnodk/u
Any teeth treated with root canals or pulpotomies?*

yesnodk/u
"Gum boils", frequent canker sores or cold sores?*

yesnodk/u
History of speech therapy?*

yesnodk/u
Difficulty breathing through nose?*

yesnodk/u
Food impaction between teeth?*

yesnodk/u
Mouth breathing habit or snoring at night?*

yesnodk/u
History of speech problems?*

yesnodk/u
Frequent oral habits (sucking finger, chewing pen, etc)?*

yesnodk/u
Teeth causing irritation to lip, cheek or gums?*

yesnodk/u
Abnormal swallowing (tongue thrust)?*

yesnodk/u
Tooth grinding or clenching?*

yesnodk/u
Clicking, locking in jaw joints?*

yesnodk/u
Soreness in jaw muscles or face muscles?*

yesnodk/u
Ringing in ears, difficulty in chewing or opening jaw?*

yesnodk/u
Have you been treated for TMJ or TMD problems?*

yesnodk/u
Any broken or missing fillings?*

yesnodk/u
Any serious trouble associated with previous dental treatment?*

yesnodk/u
Have you ever been diagnosed with gum disease or pyorrhea?*

yesnodk/u
Have you ever had an orthodontic consultation or treatment before now?*

yesnodk/u
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for:
Medication
Taken for:
Medication
Taken for:
If you have ever taken any medications to strengthen your bones, please explain.
Do you take antibiotic pre-medication before any dental procedure?*

yesno
Do you or have you ever had a substance abuse problem?*
Do you chew or smoke tobacco?*
If you have noticed changes in your face or jaw, please explain.
If you have any other physical problems, please explain.
How often do you brush?*
How often do you floss?*
Women: Are you pregnant?

yesno
Women: Are you trying to become pregnant?

yesno
FAMILY MEDICAL HISTORY
If your parents or siblings ever had any of the following health problems, please explain.
Bleeding disorders
Diabetes
Severe allergies
Arthritis
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
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.
Patient Signature *

Clear
Today's Date

MonthDayYear
Should be Empty:

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER