schmidlorthodontics - Adult Medical Dental History Form

CONFIDENTIAL

Medical Dental History Form for Adult Patients
PATIENT
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Patient's name

Last NameFirst NameMiddle Initial
Title

Other
I prefer to be called
Birth date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Sex
Social Security #
Marital Status
Home address

Apt #

CityState

Zip Code
Cell phone
Format: (000) 000-0000.
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
E-mail address(es)
Occupation
Employer
CLOSEST RELATIVE
Spouse or closest relative’s name(s)
Title

Other
Relationship to patient
Address (if different than patient address)

Apt #

CityState

Zip Code
Cell Phone
Format: (000) 000-0000.
Home phone

Area CodePhone Number
Work phone

Area CodePhone Number
DENTIST
Patient’s Dentist
Address

CityState

Zip Code
Last seen

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Reason
Next appointment
Other dentists/dental specialists now being seen
Name
Address

CityState

Zip Code
Reason
PHYSICIAN
Patient’s Physician
City, State
Last seen

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Reason
Next appointment

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Most recent physical exam
Other physicians/health care providers being seen now

Rows	Name	City, State	Reason
1
2
3
4
5
6

GENERAL INFORMATION
What concerns you about your teeth?
Who suggested that you might need orthodontic treatment?
Why did you select our office?
Have you had any previous orthodontic treatment? Please describe
Have any other family members been treated in this office? Please name them
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
RELEASE AND WAIVER

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
MEDICAL HISTORY UPDATES OR CHANGES
Changes
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Dental Staff Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Changes
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Dental Staff Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Changes
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Dental Staff Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Please also fill out our auto-pay authorization form located here
Should be Empty:

Rows	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?

Rows	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

Rows	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

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

Rows	Medication	Taken for
1
2
3
4
5
6

Rows	Medication	Taken for
1
2
3
4
5