Sutton - Medical/Dental History Form (Adult Ortho)

Medical Dental History Form for Adult Patient
Date*

MonthDayYear
Date
Patient's last name*
First name*
Middle initial*
Title*

Mr.Mrs.Ms.Miss.Dr.Other
I prefer to be called*
Birth date*

MonthDayYear
Date
Sex*

MaleFemale
Social Security #*
Marital Status*

SingleMarriedSeparatedDivorcedWidowed
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone*

Area CodePhone Number
Cell phone*

Area CodePhone Number
Work phone*

Area CodePhone Number
Email*
example@example.com
Occupation*
Employer*
Closet Relative
Spouse or closet relative name(s)*
Title*

Mr.Mrs.Ms.Miss.Dr.Other
Relationship to patient*
Address (if different than patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone (if different)

Area CodePhone Number
Dentist
Patient's Dentist*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last seen*
Reason*
Next Appointment*
Other dentists/dental specialist now being seen: Name
City, State*
Reason*
Physician
Patient's Physician*
City, State*
Last seen*
Reason*
Next appointment*
Most recent physical exam*
Other physician/health care providers being seen now:
Name
City, State
Reason
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.
Have any other family member been treated in the office? Please name them.
Do you think that any of your work or leisure activities affect you teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account?*
Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City, State, Zip
Home phone*

Area CodePhone Number
Cell phone*

Area CodePhone Number
Email address*
example@example.com
Social Security #*
Employer*
Dental Insurance
Primary policy holder's full name*

First NameLast Name
Birth date*

MonthDayYear
Date
Social Security #*
Relationship to patient*
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (if not listed above)

Area CodePhone Number
Employer*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company*
Group #*
ID#*
Does this policy have orthodontic benefits?*

YesNoDon't Know
Secondary policy holder's full name
Birth date

MonthDayYear
Date
Social Security #
Relationship to patient
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company
Group #
ID#
Does this policy have orthodontic benefits?

YesNoDon't Know
Medical Insurance
Policy holder's full name*
Insurance Company*
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
Birth defects or hereditary problems?*
Bone fractures or major injuries? *
Any injuries to face, head, neck? *
Arthritis or joint problems? *
Endocrine or thyroid problems? *
Diabetes or low sugar? *
Kidney problems?*
Cancer, tumor, radiation treatment or chemotherapy? *
Stomach ulcer, hyperacidity, acid reflux? *
Immune system problems?*
History of osteoporosis? *
Gonorrhea, syphilis, herpes, sexually transmitted diseases?*
AIDS or HIV positive? *
Hepatitis, jaundice, or other liver problems?*
Polio, mononucleosis, tuberculosis, pneumonia? *
Seizures, fainting spells, neurologic problems?*
Mental health disturbance or depression?*
Vision, hearing, or speech problems? *
History of eating disorder (anorexia, bulimia)? *
High or low blood pressure?*
Excessive bleeding or bruising, anemia? *
Chest pain, shortness of breath, tire easily, swollen ankles? *
Heart defects, heart murmur, rheumatic heart disease? *
Angina, arteriosclerosis, stroke or heart attack?*
Skin disorder (other than common acne)? *
Do you eat a well-balanced diet? *
Frequent headaches or migraines? *
Frequent ear infections, colds, throat infections? *
Asthma, sinus problems, hayfever? *
Tonsil or adenoid condition? *
Do you frequently breathe through your mouth?*
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine) *
Latex (gloves, balloons) *
Aspirin*
Metals (jewelry, clothing snaps) *
Penicillin*
Other antibiotics*
Ibuprofen (Motrin, Advil) *
Acrylics*
Plant pollens *
Animals*
Foods*
Other substances
Dental History

Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed? *
Supernumerary (extra) or congenitally missing teeth? *
Chipped or injured primary or permanent teeth? *
Any sensitive or sore teeth? *
Bleeding gums, bad taste or mouth odor? *
Jaw fractures, cysts, infections? *
Any teeth treated with root canals or pulpotomies? *
“Gum boils,” frequent canker sores or cold sores? *
History of speech problems or speech therapy? *
Difficulty breathing through nose? *
Food impaction between the teeth?*
Mouth breathing habit or snoring at night? *
Frequent oral habits (sucking finger, chewing pen, etc)? *
Teeth causing irritation to lip, cheek or gums? *
Abnormal swallowing (tongue thrust)? *
Tooth grinding or clenching? *
Clicking, locking in jaw joints? *
Soreness in jaw muscles or face muscles? *
Ringing in ears, difficulty in chewing or opening jaw? *
Have you ever been treated for “TMJ” or “TMD” problems? *
Any broken or missing fillings? *
Any serious trouble associated with previous dental treatment? *
Have you ever been diagnosed with gum disease or pyorrhea? *
Have you ever had an orthodontic consultation or treatment before now?*
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
Have you ever taken any medications to strengthen your bones? Please describe. *
Do you take antibiotic pre-medication before any dental procedures? *
Do you or have you ever had a substance abuse problem?*
Do you chew or smoke tobacco? *
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.*
Bleeding disorders *
Diabetes
Arthritis*
Severe allergies *
Unusual dental problems *
Jaw size imbalance *
Other family medical conditions? *
Release and Waiver

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

Clear
Date*

MonthDayYear
Date
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.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical Dental History Form for Adult Patient

Closet Relative

Dentist

Physician

General Information

Financial Responsibility

Dental Insurance

Medical Insurance