Adult Health Form
Personal Information
Name
*
First Name
Last Name
Title
*
Please Select
Mr.
Ms.
Mrs.
Dr.
Preferred Name
*
Gender
*
Male
Female
Birthdate
*
-
Month
-
Day
Year
Date
Age
*
SSN#
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
*
example@example.com
Preferred Contact
Home
Cell
Work
Email
Employer
How Long There?
Occupation
Marital Status
Single
Married
Divorced
Widowed
Separated
If Married, Spouse's Name
If Married, Spouse's Phone
Please enter a valid phone number.
Dental Insurance
Orthodontic Benefits?
Yes
No
Unsure
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Group Policy Number
Secondary Dental Insurance
Insurance Company Name
Insurance Company Phone
Please enter a valid phone number.
Group Policy Number
If the primary insured person for either insurance(s) is someone other than you, please provide the following:
Insured's Name
First Name
Last Name
Insured's Relation
Insured's Birthdate
-
Month
-
Day
Year
Date
Insured's SSN#
Insured's Employer
Are you responsible for the account?
Yes
No
If no, please name:
Medical History
Do you have a primary care physician?
Yes
No
Physician's name
Physician's Phone
Please enter a valid phone number.
Last Visit
-
Month
-
Day
Year
Date
Your Current Physical Health is...
Good
Fair
Poor
Height
Weight
Are You Currently Under the Care of a Physician?
Yes
No
If Yes, Please Explain
Do You Smoke or Use Tobacco in Any Form?
Yes
No
Do You Use Recreational Drugs?
Yes
No
Have you had any metal rods, pins, or implants?
Yes
No
Please list any prescriptions or over-the-counter drugs you take and the reason for medication:
Have you ever taken Fosomax, Actonel, Boniva, or any other form of Bisphosphonate?
Yes
No
Please select if you have or have had any of the following conditions
AIDS/HIV
Alcohol/Drug Abuse
Anemia
Arthritis
Artificial Joints/Valves
Asthma
Blood Transfusion
Cancer/Chemotherapy
Colitis/Cold Sores
Congenital Heart Defect
Diabetes
Difficulty Breathing
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack/Surgery
Heart Murmur
Hemophilia/Blood Disorder
Hepatitis
Herpes/Fever Blisters
High Blood Pressure
Kidney Problems
Liver Disease
Low Blood Pressure
Lupus
Mitral Valve Problems
Pacemaker
Psychiatric Problems
Radiation Treatment
Rheumatic/Scarlet Fever
Seizures
Shingles
Sickle Cell Disease/Trait
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcers
Venereal Disease
Other medical condition(s)
Do you have any allergies?
Yes
No
If yes, please select all that apply
Aspirin
Metals/Nickel
Advil/Ibuprofen
Penicillin
Latex
Codeine
Dogs
Please list any other allergies and reactions
Women Only
Are you pregnant?
Yes
No
If yes, week number
Are you nursing?
Yes
No
Are you planning to become pregnant in the next two years?
Yes
No
Dental History
General Dentist
Last Visit
-
Month
-
Day
Year
Date
Reason for Visit
Other Dental Specialists Seen Routinely
Orthodontic History
List any concerns you have about your smile and/or bite
Who may we thank for referring you to our office?
Please list any other family members seen by us
Have you ever had orthodontic treatment?
*
Yes
No
If yes, please explain
Have you ever been evaluated by an orthodontist?
*
Yes
No
Has anyone if your family had jaw surgery to correct their bite?
*
Yes
No
History of facial birth defects or cleft palate?
*
Yes
No
Have you ever been diagnosed with sleep apnea?
*
Yes
No
Have you ever been diagnosed with speech problems?
*
Yes
No
Do you commonly snore?
*
Yes
No
Do you grind or clench your teeth?
*
Yes
No
Have you ever had major trauma/inury to your face, jaw, teeth or mouth?
*
Yes
No
Have you ever been treated for TMJ/TMD?
*
Yes
No
Do you experience discomfort/pain in your jaw joints?
*
Yes
No
Does your jaw routinely pop or click?
*
Yes
No
Has your jaw ever locked closed or open?
*
Yes
No
Do you have frequent headaches/migraines?
*
Yes
No
Do you wear a mouthguard at night?
*
Yes
No
Do you experience pain or ringing in your ears?
*
Yes
No
How do you typically breath?
*
Through my mouth
Through my nose
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
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