Adult Patient Health History Form

Adult Patient Health History Form
About You
Today's Date *

Month Day Year
Date
Name *

First Name Last Name
Preferred Name/Nickname
Address
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell *
Carrier *
DOB *

Month Day Year
Date
Age *
Sex *

Male Female
Employer *
Day Time Phone *
Email *
example@example.com
Spouse's Name *
How did you hear about our office? *
What is the reason you are seeking an orthodontic evaluation? *
Has an orthodontist been consulted previously? *

Yes No
If Yes, Reason *
Please list other family members seen in our office and their relationship to this patient *
Medical Health Information
Have you been hospitalized for any surgical procedure or serious illness? *

No Yes
If Yes, Explain
Physician: *
Physician Phone *
Do you have or have you had any of the following diseases or conditions? (Check all those that apply)

Diabetes Stroke Asthma Hepatitis Tonsillitis Fainting Spells Seizures Scarlet Fever Rheumatic Heart Disease Allergies (medicine or other) Latex or Nickel Sensitivity/Allergy High or Low Blood Pressure Heart Defect, Heart Murmur, Heart Disease AIDS, HIV Positive Herpes, Fever Blisters Joint Replacement or Implant Excessive Bleeding or Bruising
Do you or have you ever taken bisphosphonates, including Fosamax, Didronel, Boniva, Aredia, Actonel, Skelid or Zometa? *

Yes No
If Yes, which drug?
Do you have any disease, condition, or problem not listed that you think we should know about? Please explain: *
Are you taking any medication at this time? Please explain: *
Dental Insurance Information
Primary Insurance Company Name *
Primary Insurance Company Address
Group/Plan Number *
Primary Policy Holder Name *
Social Security Number *
Primary Insurance Holder's DOB *

Month Day Year
Date
Secondary Insurance Company Name
Address
Group or Plan Number
Secondary Policy Holder Name
Policy Holder Social Security Number
Date of Birth

Month Day Year
Date
Do you participate in a flex plan?

Yes No
Dental Health Information
Are you experiencing any dental problems? *

Yes No
Estimated Date of last dental visit: *
How often to you brush and floss?
Brush per day *
Floss per week *
Dentist *
Phone
Address (Street, City, Zip)
Do you have any of the following habits or problems? (Check all that apply)

Jaw Pain (Joint, Ear, Side of face) Snoring/Sleep Apnea Chronic Mouth Breathing Clenching or Grinding Finger or Lip Sucking Habit Difficulty Chewing Tooth Sensitivity to Heat, Cold or Sweets Head/Neck, Jaw or Tooth Injury Missing Permanent Teeth Clicking or Popping of the Jaw Joints Previous Orthodontic Treatment
Photo Release
I hereby consent to and authorize the use and reproduction, in print or electronic format, by Local Orthodontics, of any and all photographs which have been taken for any marketing/advertising purposes, without compensation. All images are owned by Local Orthodontics. *

Accept Decline
I acknowledge that the above information is correct. I will notify Dr. Jewett of any changes that occur after this date. I hereby authorize Dr. Jewett and his team to perform an initial orthodontic evaluation/examination.
Signature

Clear
Date *

Month Day Year
Date
Should be Empty:

Adult Patient Health History Form

About You

Address

Medical Health Information

Dental Insurance Information

Dental Health Information

Photo Release