schmidlorthodontics - Adult Medical Dental History Form

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (if different from above page 1)

Apt #

CityState

Zip Code

Cell phone

Home phone

Area CodePhone Number

E-mail address(es)

Social Security #

Employer

Who will be responsible for bringing the patient to orthodontic appointments?

DENTAL INSURANCE

Primary policy holder’s full name

Birth date

Social Security #

Relationship to patient

Address (if not listed above)

CityState

Zip Code

Phone Number (if not listed above)

Area CodePhone Number

Employer

Address

CityState

Zip Code

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

YesNoDon’t know

Secondary policy holder’s full name

Birth date

Social Security #

Relationship to patient

Address (if not listed above)

CityState / Province

Postal / Zip Code

Phone Number (if not listed above)

Area CodePhone Number

Employer

Address

CityState

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, mark yes, no, or don’t know/understand (dk/u)

MEDICAL HISTORY

Now or in the past, have you had

	Yes	No	dk/u
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates as Zometa (zolendromic acid), Aredia pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?
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 problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
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

	Yes	No	dk/u
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods

Other substances

YesNodk/u

Please Explain

DENTAL HISTORY

Now or in the past, have you had

	Yes	No	dk / U
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?
History of speech problems?
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 associate 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
1
2
3
4
5
6

Do you take antibiotic pre-medication before any dental procedures?

YesNo

	Medication	Taken for
1
2
3
4
5

Have you ever taken any medications to strengthen your bones? Please describe

Do you or have you ever had a substance abuse problem?

Have you chewed tobacco

YesNo

Smoked any substance or vaped?

YesNo

If yes, what is the frequency?

Have you noticed any changes in your face or jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

WOMEN

Are you pregnant?

YesNo

Are you trying to become pregnant?

YesNo

CONFIDENTIAL

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

Other dentists/dental specialists now being seen

PHYSICIAN

Other physicians/health care providers being seen now

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

WOMEN

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES OR CHANGES

	Name	City, State	Reason
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2
3
4
5
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