Medical Dental History Form for Adult Patients

Medical Dental History Form for Adult Patients
PATIENT INFORMATION
Date*

MonthDayYear
Date
Name*

First nameMiddle initialPatient's Last name
Title

Mr.Mrs.Ms.Miss.OtherDr.Other
I prefer to be called
Birth date*

MonthDayYear
Date
Sex

MaleFemale
Social Security #
Marital Status

SingleMarriedSeperatedDivorcedWidowed
Address*

Home address

Street Address Line 2

City, State, Zip codeState / Province

Postal / Zip Code
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
CLOSEST RELATIVE
Spouse or closest relatives name(s)
Title

Mr.Mrs.Ms.Miss.OtherDr.Other
Relationship to patient
Address (if different than patient address)
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
Work phone

Area CodePhone Number
DENTIST
Patient’s Dentist
Address, City, State
Last seen
Reason
Next appointment
Other dentists/dental specialists now being seen:
Name
City, State
Reason
PHYSICIAN
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City, State
Reason
Name
City, State
Reason
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.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address

Address (if different from page 1)

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Home phone

Area CodePhone Number
Cell phone

Area CodePhone Number
E-mail address(es)
example@example.com
Social Security #
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
DENTAL INSURANCE
Primary policy holder’s full name
Birth date

MonthDayYear
Date
Social Security
Relationship to patient
Address and phone (if not listed above)

Area CodePhone Number
Employer
Address
Insurance company
Group
ID
Does this policy have orthodontic benefits?

YesNoDon't Know
Secondary policy holder’s full name
Birth date

MonthDayYear
Date
Social Security
Relationship to patient
Address and phone (if not listed above)

Area CodePhone Number
Employer
Address
Insurance company
Group
ID
Does this policy have orthodontic benefits?

YesNoDon't Know
MEDICAL INSURANCE
Policy holder’s full name
Insurance company
Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation.

For the following questions mark yes, no, or don't know/understand (dk/u
MEDICAL HISTORY

Now or in the past, have you had:
Birth defects or hereditary problems?

yesnodk/u
Bone fractures, or major injuries?

yesnodk/u
Any injuries to face, head, neck?

yesnodk/u
Arthritis or joint problems?

yesnodk/u
Endocrine or thyroid problems?

yesnodk/u
Diabetes or low blood sugar?

yesnodk/u
Kidney problems?

yesnodk/u
Cancer, tumor, radiation treatment or chemotherapy?

yesnodk/u
Stomach ulcer, hyperacidity, acid reflux?

yesnodk/u
Immune system problems?

yesnodk/u
History of osteoporosis?

yesnodk/u
Gonorrhea, syphilis, herpes, sexually transmitted diseases?

yesnodk/u
AIDS or HIV positive?

yesnodk/u
Hepatitis, jaundice or other liver problem?

yesnodk/u
Polio, mononucleosis, tuberculosis, pneumonia?

yesnodk/u
Seizures, fainting spells, neurologic problem?

yesnodk/u
Mental health disturbance or depression?

yesnodk/u
Vision, hearing, or speech problems?

yesnodk/u
History of eating disorder (anorexia, bulimia)?

yesnodk/u
High or low blood pressure?

yesnodk/u
Excessive bleeding or bruising, anemia?

yesnodk/u
Chest pain, shortness of breath, tire easily, swollen ankles?

yesnodk/u
Heart defects, heart murmur, rheumatic heart disease?

yesnodk/u
Angina, arteriosclerosis, stroke or heart attack?

yesnodk/u
Skin disorder (other than common acne)?

yesnodk/u
Do you eat a well-balanced diet?

yesnodk/u
Frequent headaches or migraines?

yesnodk/u
Frequent ear infections, colds, throat infections?

yesnodk/u
Asthma, sinus problems, hayfever?

yesnodk/u
Tonsil or adenoid condition?

yesnodk/u
Do you frequently breathe through your mouth?

yesnodk/u
MEDICAL HISTORY

Now or in the past, have you had:
Permanent or extra (supernumerary) teeth removed?

yesnodk/u
Supernumerary (extra) or congenitally missing teeth?

yesnodk/u
Chipped or injured primary or permanent teeth?

yesnodk/u
Any sensitive or sore teeth?

yesnodk/u
Bleeding gums, bad taste or mouth odor?

yesnodk/u
Jaw fractures, cysts, infections?

yesnodk/u
Any teeth treated with root canals or pulpotomies?

yesnodk/u
“Gum boils,” frequent canker sores or cold sores?

yesnodk/u
History of speech problems or speech therapy?

yesnodk/u
Difficulty breathing through nose?

yesnodk/u
Food impaction between the teeth?

yesnodk/u
Mouth breathing habit or snoring at night?

yesnodk/u
History of speech problems?

yesnodk/u
Frequent oral habits sucking finger, chewing pen, etc?

yesnodk/u
Teeth causing irritation to lip, cheek or gums?

yesnodk/u
Abnormal swallowing (tongue thrust)?

yesnodk/u
Tooth grinding or clenching?

yesnodk/u
Clicking, locking in jaw joints?

yesnodk/u
Soreness in jaw muscles or face muscles?

yesnodk/u
Ringing in ears, difficulty in chewing or opening jaw?

yesnodk/u
Have you ever been treated for “TMJ” or “TMD” problems?

yesnodk/u
Any broken or missing fillings?

yesnodk/u
Any serious trouble associate with previous dental treatment?

yesnodk/u
Have you ever been diagnosed with gum disease or pyorrhea?

yesnodk/u
Have you ever had an orthodontic consultation or treatment before now?

yesnodk/u
Have you had allergies or reactions to:
Local anesthetics (novocaine, lidocaine, xylocaine)?

yesnodk/u
Latex (gloves, balloons)?

yesnodk/u
Aspirin?

yesnodk/u
Ibuprofen (Motrin, Advil)?

yesnodk/u
Penicillin?

yesnodk/u
Other antibiotics?

yesnodk/u
Metals (jewelry, clothing snaps)?

yesnodk/u
Acrylics?

yesnodk/u
Plant pollens?

yesnodk/u
Animals?

yesnodk/u
Foods?

yesnodk/u
Other substances?

yesnodk/u
Please explain:
PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
Any other physical problems?
How often do you brush?
How often do you floss?
Women: Are you pregnant?

YesNo
Are you trying to become pregnant?

YesNo
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*

Clear
Date*

MonthDayYear
Date
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*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical Dental History Form for Adult Patients

PATIENT INFORMATION

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

MEDICAL HISTORY

Have you had allergies or reactions to:

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER