tennisonortho.com-MEDICAL DENTAL HISTORY

CONFIDENTIAL

Date

Patient’s name

First Name Middle Name Last Name

Birth date

Age

Sex

Male Female

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:

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

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

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?

Yes No

Insurance coverage for orthodontic treatment?

Yes No

Primary policy holder’s name

First Name Last Name

Social Security number

Birth date

Employed by

Dental insurance company

Group number

Secondary policy holder’s name

First Name Last Name

Social Security number

Birth date

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.

Yes No dk/u

Medication

Taken for

1

2

3

Yes /No/ dk/u

Describe

Operations?

Hospitalized?

MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS