Adult Health History Form

Adult Health History Form
Patient Preferred Name*
Patient Preferred Pronouns*
Patient Name*

First NameLast Name
Who can we thank for referring you to our office if other than your dentist?

First NameLast Name
Patient Occupation / School
Patient Birth Date*

MonthDayYear
Date
Sex*

MaleFemale
Patient Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
General Dentist

First NameLast Name
Office Phone

Area CodePhone Number
List any known allergies:
Sensitivity to latex?*

YesNo
Responsible Party Information

This office reserves the right to verify the credit status of potential patients seeking payment terms.
Patient Full Name*

First NameLast Name
Marital Status*

MarriedDivorcedWidowedSinglePartnership
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email*
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)*
Birth Date*

MonthDayYear
Date
Employer
Occupation
Years Employed
Spouse (Partner) Name

First NameLast Name
Marital Status*

MarriedDivorcedWidowedSinglePartnership
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date

MonthDayYear
Date
Employer
Occupation
Years Employed
Dental Insurance Information

(Please provide copy of insurance card to office)
Do you have DENTAL Insurance?*

YesNo
If yes, Primary Insurance Company:*
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company Phone*

Area CodePhone Number
Name of Employer*
Group No.*
ID #*
Employee Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Employee Home Address (If different than patient)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient*
Employee Social Security #*
Upload photo of front and back of insurance card*

Browse Files

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Do you have Secondary Insurance?*

YesNo
Secondary Insurance Company*
Insurance Co. Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Co. Phone*

Area CodePhone Number
Name of Employer*
Group No.*
ID #*
Employee Name*
Date of Birth*

MonthDayYear
Date
Employee Home Address (if different than patient)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employee relationship to patient*
Employee Social Security #*
Upload photo of front and back of insurance card*

Browse Files

Cancelof
Name of emergency contact (not living in your home)*
Phone*

Area CodePhone Number
Complete Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Is this patient in good health?*

YesNo
Primary Physician*
Medical Specialist(s)*
Are you being treated by a physician at this time? (Include reason) *
Are you taking any medications? (If so, please list)*
Known allergy or sensitivity to latex?*
Known allergy or sensitivity to metals?*
List any known allergies:*
Are you up to date on immunizations?*
Please mark yes or no for each of the following, if you answered yes to any question, please provide details in space below question. Do you have or have a history with any of the following:
Complications before or during birth, prematurity, birth defects, syndromes, or inherited conditions*

YesNo
If yes, please explain:
Problems with physical growth or development*

YesNo
If yes, please explain:
Large tonsils (tonsils or adenoids removed), sleep apnea, snoring, or mouth breathing*

YesNo
If yes, please explain:
Excessive gagging*

YesNo
If yes, please explain:
Asthma*

YesNo
If yes, please explain:
RSV*

YesNo
If yes, please explain:
Diabetes, hyperglycemia, or hypoglycemia*

YesNo
If yes, please explain:
Congenital heart defect/disease, murmur, rheumatic fever/heart disease*

YesNo
If yes, please explain:
High blood pressure*

YesNo
If yes, please explain:
Frequent cold/cough, pneumonia*

YesNo
If yes, please explain:
Hepatitis or Liver problems*

YesNo
If yes, please explain:
GERD, reflux, or gastrointestinal issues*

YesNo
If yes, please explain:
Concerns with weight or eating disorders*

YesNo
If yes, please explain:
Bladder or kidney problems*

YesNo
If yes, please explain:
Anemia or prolonged bleeding*

YesNo
If yes, please explain:
Endocrine, thyroid, or pituitary problems*

YesNo
If yes, please explain:
Bone, muscle, or joint problems*

YesNo
If yes, please explain:
Impaired vision, hearing, or speech*

YesNo
If yes, please explain:
Developmental, behavioral, or learning disorders*

YesNo
If yes, please explain:
Epilepsy*

YesNo
If yes, please explain:
ADD/ADHD*

YesNo
If yes, please explain:
Autism spectrum disorder*

YesNo
If yes, please explain:
Fainting, dizziness, or recurrent headaches*

YesNo
If yes, please explain:
Cancer*

YesNo
If yes, please explain:
Mononucleosis (Mono)*

YesNo
If yes, please explain:
Tuberculosis (TB)*

YesNo
If yes, please explain:
Sexually transmitted disease (STD)*

YesNo
If yes, please explain:
HIV/AIDS*

YesNo
If yes, please explain:
Hospitalizations or surgeries*

YesNo
If yes, please explain:
Any other significant medical history:
If female, are you pregnant?

YesNo
Dental History
What concerns you most about your teeth and facial appearance? *
How would you describe your oral health? *
Do you grind or clench your teeth?*

YesNo
Do you have any speech problems?*

YesNo
Have you been informed of any missing or extra teeth?*

YesNo
Has an orthodontist been consulted previously?*

YesNo
Have you had previous orthodontic treatment?*

YesNo
Have other members of your family had orthodontic treatment?*

YesNo
Has anyone in your family been seen in our office? Name(s)*
Does anyone in your family have a similar dental problem?*
Have you had a negative dental experience?*
The above information is correct to the best of my knowledge.
Signature*

Clear
Date Submitted*

MonthDayYear
Date
Should be Empty:

Adult Health History Form

Responsible Party Information

Dental Insurance Information

Medical History

Dental History