tennisonortho.com-MEDICAL DENTAL HISTORY

MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS
CONFIDENTIAL
Date

MonthDay Year
Patient’s name

First Name Middle Name Last Name
Birth date

MonthDay Year
Age
Sex

MaleFemale
Name I prefer to be called
Social Security number
Home phone number

Area Code Phone Number
Email address
example@example.com
Cell phone/pager
Patient’s address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Years at above address
If less than 5 years at current address, previous address:
Years at previous address
Occupation
Employer
Years with Employer
Business phone number

Area Code Phone Number
Name of spouse/closest relative
Phone number (if difference from yours)

Area Code Phone Number
Relationship to you
Address (if different from yours)

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Other family members treated here:
Name of patient’s dentist

First Name Last Name
Phone number

Area Code Phone Number
Dentist’s address:

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date last seen:

MonthDay Year
Reason:
Name of patient’s physician

First Name Last Name
Phone Number

Area Code Phone Number
Dentist’s address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date last seen

MonthDay Year
Reason:
Name of patient’s physician

First Name Last Name
Phone number

Area Code Phone Number
Physician’s address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Date last seen

MonthDay Year
Reason:
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Who is financially responsible for this account? (Name)

First Name Middle Name Last Name
Address (if different from patient’s)

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Years at this address
Insurance coverage for dental treatment?

YesNo
Insurance coverage for orthodontic treatment?

YesNo
Primary policy holder’s name

First Name Last Name
Social Security number
Birth date

MonthDay Year
Employed by
Dental insurance company
Group number
Secondary policy holder’s name

First Name Last Name
Social Security number
Birth date

MonthDay Year
Employed by
Dental insurance company
Group number
For the following questions, mark yes, no, or don’t know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

MEDICAL HISTORY

Now or in the past, have you had:

	Yes	No	dk/u
Birth defects or hereditary problems?
Bone fractures, any major accidents?
Rheumatoid or arthritic conditions?
Diabetes?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer or hyperacidity?
Problems of the immune system?
AIDS or HIV positive?
Hepatitis, jaundice or liver problem?
Fainting spells, seizures, epilepsy or
neurological problem?
Mental health disturbance or depression?
Vision, hearing, tasting or speech difficulties?
History of eating disorder (anorexia, bulimia)?
Excessive bleeding or bruising tendency,
anemia or bleeding disorder?
High or low blood pressure?
Chest pain, shortness of breath or swelling ankles?
Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)?
Skin disorder?
Frequent headaches, colds or sore throats?
Eye, ear, nose or throat condition?
Do you currently have or ever had a substance abuse problem?
Do you chew or smoke tobacco?
Tonsil or adenoid conditions?
Osteoporosis?

Allergies or reactions to any of the following?

	Yes	No	dk/u
Local anesthetics (Novocaine or Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin or other antibiotics
Sulfa drugs
Codeine or other narcotics
Metals (jewelry, clothing snaps)
Latex (gloves, balloons)
Vinyl
Acrylic
Other substances

Other substances (specify)
Are you taking medication, nutrient supplements, herbal medications or nonprescription medicine? Please name them.

YesNodk/u
Medication Taken for
1
2
3
Yes /No/ dk/u Describe
Operations?
Hospitalized?
Other physical problems or symptoms?
Being treated by another health care professional?

YesNodk/u
For
Date of most recent physical exam?

MonthDay Year
Do you have any other medical conditions that we should know about?
WOMEN ONLY
Are you pregnant?

YesNodk/u
FAMILY MEDICAL HISTORY

Do your parents or siblings have any of the following health problems? If so, please explain:

	.
Bleeding disorders
Severe allergies
Diabetes
Unusual dental problems
Arthritis
Jaw size imbalance
Any other family medical conditions that we should know about?

DENTAL HISTORY

Now or in the past, have you:

	Yes	No	dk/u
Had permanent or "extra" (supernumerary) teeth removed?
Chipped or otherwise injured primary (baby) or permanent teeth?
Had jaw fractures, cysts or mouth infections?
Had "dead teeth" or root canals treated?
Had periodontal "gum problems"?
Had thumb, finger, or sucking habit?
Had a history of speech problems?
Had tooth grinding or jaw clenching?
Had any pain in jaw or ringing in the ears?
Encountered difficulty in chewing or jaw opening?
Been aware of loose, broken or missing restorations (fillings)?
Been concerned about spaced, crooked or protruding teeth?
"Gum boils," frequent canker sores or cold sores?
Had any relative with similar tooth or jaw relationships?
Would you object to wearing orthodontic appliances (braces), should they be indicated?
Had supernumerary (extra) or congenitally missing teeth?
Had any wisdom tooth problems?
Had teeth sensitive to hot or cold, teeth throb or ache?
Had bleeding gums, bad taste or mouth odor?
Had food impaction between teeth?
Had an abnormal swallowing habit (tongue thrusting)?
Had a mouth breathing habit, snoring or difficulty in breathing?
Had any pain or soreness of the face or around the ears?
Had any teeth irritating cheek, lip, tongue or palate?
Been aware of or concerned about under or over developed jaw?
Had periodontal (gum) treatment?
Had any serious trouble associated with any previous dental treatment?
Have you ever had a prior orthodontic examination or treatment?

Had thumb, finger, or sucking habit? Until what age?

	Yes/No/Dk/u	Specialist	Other
Have you been under another dentist’s care?

How often do you brush:
Floss:
What is your primary concern? Why are you here?
I have read and understand the above questions. 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. If there are any changes later to the history record or medical/dental status, I will so inform the practice.
Patient Signature

Clear
Date signed:

MonthDay Year
Dental staff member Signature

Clear
Date signed:

MonthDay Year

	Yes /No/ dk/u	Describe
Operations?
Hospitalized?
Other physical problems or symptoms?

	Medication	Taken for
1
2
3

MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS