Smith + Heymann Ortho Adult Medical/Dental History Form

Adult Medical/Dental History Form
Patient's Name *

First Name Last Name
Name of Person/Persons Completing Form *
Prefers to be addressed as
Gender *

Male Female
Age *
Birthdate *

Month Day Year
Date
Patient's Phone Number *
Please enter a valid phone number.
Patient's Email *
example@example.com
Preferred way to receive reminders: *

Text Email Both
Patient's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Who may we thank for referring you?
What helped you decide to contact Smith & Heymann Orthodontics? *

Friends Family Social Media Our Website Online Reviews Other
Marital Status *

Single Married Divorced Separated Widowed
Do you have children? If yes, please list their names and ages below.
Contact in case of Emergency (Name) *

First Name Last Name
Phone *
Please enter a valid phone number.
Cell
Please enter a valid phone number.
Dental Insurance

In order to verify ortho coverage and retrieve benefits, we must have member ID or social if no member id was provided.
Do you have Dental Insurance? *

Yes No
If yes, please provide details below.
Policy Holder's Name

First Name Last Name
Primary Insurance Co
Please provide state if Delta Dental is provider
Policy Holder's Employer
SSN/Member ID
SSN/Member ID
Do You Have Ortho Coverage?

Yes No
Group #
Policy Holder’s Birthdate

Month Day Year
Date
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Secondary Insurance
Do you have secondary insurance?

Yes No
If yes, please provide secondary insurance details below.
Policy Holder's Employer
Policy Holder's Name

First Name Last Name
Secondary Insurance Co
SSN/Member ID
SSN
Do You Have Ortho Coverage?

Yes No
Group #
Policy Holder's Birthdate

Month Day Year
Date
Dental History
Do you have a Dentist? If yes, please provide details below. *

Yes No
Patient's Dentist Name
Date of Last Visit

Month Day Year
Date
Have there been any injuries to the face, mouth or teeth? *

Yes No
Have you had or do you presently have any of the following habits? *

Thumb or finger sucking Lip Biting Snoring Grinding of the teeth at night Mouth breathing None
Have you been informed of any missing or extra permanent teeth? *

Yes No
Are you aware of sores, lumps or irritated areas in the mouth? *

Yes No
Has an orthodontist been consulted previously? If yes, please provide details below. *

Yes No
Orthodontist's Name
Date of Last Orthodontic Visit

Month Day Year
Date
Have you ever been treated for *

Bad Bite TMJ Periodontal disease None
Are you frightened or anxious about Orthodontic treatment? *

Yes No
Are you concerned about the appearance of your teeth? *

Yes No
Do you have any speech problems? *

Yes No
Is there anything you would like to change about your smile?
What aspect of dental treatment are you most concerned with? *

Quality Cost Discomfort Time None
Reason for consultation (chief concern) *
Has there ever been any orthodontic treatment for any other member of your family? If yes, please provide the patient(s) names, their doctor's name, and if the patient was satisfied with treatment.
Medical History
Is your general health good at this time? *

Yes No
Comments
Are you under the care of a physician at this time? *

Yes No
If yes, please provide details
What is the name of your family physician?
Date of last physical

Month Day Year
Date
Are you taking any medication? *

Yes No
If yes, please list below.
Are you allergic to any medication? *

Yes No
If yes, please list the names of medications you are allergic to
Have you ever taken any diet medication (Fen-Phen)?

Yes No
Have you ever had a serious illness or been hospitalized? *

Yes No
Have you ever had a serious illness or been hospitalized? If yes, please explain.
Have you had your tonsils and/or adenoids removed? *

Yes No
If yes, what age?
Do you have any special conditions not listed? If yes, please explain
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments? *

Yes No
If yes, please provide antibiotic name and method.
Do you use tobacco? (smoking or chewing) *

Yes No
What is your approximate height?
What is your approximate weight?
Do you have now, or have you ever had any of the following?
Please check if YES or leave unchecked for NO:

TUBERCULOSIS ENDOCARDITIS HEART CONDITION HEART PACEMAKER HEART ANGINA HEART ATTACK (CORONARY) MITRAL VALVE PROLAPSE CONGENITAL HEART DISEASE ARTIFICIAL HEART VALVE HEART SURGERY HEART MURMUR RHEUMATIC FEVER ARTHRITIS OSTEOPOROSIS BISPHOSPHONATES PROSTHETIC (ARTIFICIAL) JOINT X-RAY/RADIATION (CANCER) THERAPY AIDS OR H.I.V. POSITIVE
Please check if YES or leave unchecked for NO:

DIABETES RESPIRATORY LUNG DISEASE HIGH BLOOD PRESSURE LOW BLOOD PRESSURE HEPATITIS VENEREAL DISEASE HERPES (ORAL-COLD SORES) BLOOD DISORDERS/BLEEDING PROBLEMS INFLAMMATORY RHEUMATISM ULCERS STROKE ANEMIA ASTHMA EPILEPSY GLAUCOMA FAINTING SPELLS
Please check if YES or leave unchecked for NO:

ADD KIDNEY TROUBLE LIVER DISEASE PSYCHIATRIC TREATMENT DRUG ADDICTION HEADACHES EARACHES JAW CLICKING ALLERGIES ALLERGIES TO METAL ALLERGIES TO LATEX JAW PAIN TONSILLITIS EMOTIONAL PROBLEMS OTHER
HIPAA Consent
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address. I have read the HIPAA Policy and agree to the terms. *

I agree
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.
Signature *

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Adult Medical/Dental History Form

Dental Insurance

If yes, please provide details below.

Secondary Insurance

If yes, please provide secondary insurance details below.

Dental History

Medical History

Do you have now, or have you ever had any of the following?

HIPAA Consent