Adult Health History Form
Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the FDA.
About You
Today's Date
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Month
-
Day
Year
Date
Full Name
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First Name
Last Name
Birth Date
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Month
-
Day
Year
Date
Age
*
Gender
*
Female
Male
Street Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
*
Single
Married
Divorced
Widowed
Separated
Home Phone
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Area Code
Phone Number
Cell Phone
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-
Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Email Address
*
Employer
Occupation
Whom may we thank for referring you?
Other family members seen by us:
Dentist Name:
Date of Last Visit
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Month
-
Day
Year
Date
Person Responsible for Account:
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Emergency Contact Information
Full Name
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First Name
Last Name
Cell Number
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-
Area Code
Phone Number
Relationship to Patient
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Medical History
Do you have a personal physician?
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Yes
No
Physician's Name
Physician's Phone
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Area Code
Phone Number
Date of Last Visit
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Month
-
Day
Year
Date
Your current physical health is:
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Good
Fair
Poor
Are you currently under the care of a physician?
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Yes
No
Please explain:
Do you smoke or use tobacco in any other form?
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Yes
No
Are you taking prescription/over-the-counter drugs?
*
Yes
No
If applicable, please list each prescription/over the counter medication you are taking and why it was prescribed:
WOMEN: Are you pregnant?
Yes
No
Week #
Have you ever had any of the following diseases or medical problems? (Please check all that apply)
Abdominal Bleeding/Hemophilia
AIDS
Alcohol/Drug Abuse
Anemia
Arthritis
Artificial Bones/Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
HIV
Hospitalized for Any Reason
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Traits
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers
Venereal Disease
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following (please check all that apply):
Dental Anesthetics
Jewelry/Metals
Latex
Antibiotics (please specify below)
Foods (please specify below)
List any other known allergies:
Dental History
What would you like orthodontics to accomplish?
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Have you ever had or been evaluated for orthodontic treatment?
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Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
*
Yes
No
Your current dental health is:
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Good
Fair
Poor
Have you ever had an injury to your (please select all that apply):
Mouth
Teeth
Chin
Do you have speech problems?
*
Yes
No
Do you breathe through your mouth?
While Awake
While Asleep
Do you like your smile?
*
Yes
No
If not, what would you like to change about your smile?
Orthodontic Insurance
Do you have orthodontic coverage?
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Yes
No
Do you have dental coverage?
*
Yes
No
Insurance Company Name
Insurance Company Phone
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Area Code
Phone Number
Employer's Phone Number
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Area Code
Phone Number
Group Number (Plan, Local or Policy #)
Insured's Name
First Name
Last Name
Relation
Insured's Birthdate
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Month
-
Day
Year
Date
Insured's ID and/or SSN #:
Insured's Employer
Employer's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Orthodontic Information Release Per HIPAA
Under the law, we must have your signature on a dated consent form and/or an authorization form of the acknowledgement of this notice, before we will use or disclose your PHI for certain purposes.
Patient Name
First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
When necessary, may we release your information to an approved third party with your consent?
Yes
No
Who can this information be released to?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent. Prompt notification of any medical and/or insurance changes during active treatment is highly recommended. Failure to communicate changes in insurance may affect your coverage resulting in a decreased insurance benefit. I understand that I am responsible for payment of services rendered and for paying any co-payment that my insurance does not cover, including the deductible. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature
*
Clear
Signature of Periago Staff
Clear
Date
*
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Month
-
Day
Year
Date
Submit
Should be Empty: