Medical Dental History Form for Adult Patients

  • Medical Dental History Form for Adult Patients

  • PATIENT INFORMATION

  • Date*
     / /
  • Title

  • Birth date*
     / /
  • Sex
  • Marital Status
  •  -
  •  -
  •  -

  • CLOSEST RELATIVE

  • Title

  •  -
  •  -
  •  -

  • DENTIST

  • Other dentists/dental specialists now being seen:

  • PHYSICIAN

  • Other physicians/health care providers being seen now:

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

  •  -
  •  -

  • DENTAL INSURANCE

  • Birth date
     / /
  •  -
  • Does this policy have orthodontic benefits?
  • Birth date
     / /
  •  -
  • Does this policy have orthodontic benefits?

  • MEDICAL INSURANCE

  • 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?
  • Bone fractures, or major injuries?
  • Any injuries to face, head, neck?
  • Arthritis or joint problems?
  • Endocrine or thyroid problems?
  • Diabetes or low blood 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?

  • MEDICAL HISTORY

    Now or in the past, have you had:
  • 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?

  • Have you had allergies or reactions to:

  • Local anesthetics (novocaine, lidocaine, xylocaine)?
  • Latex (gloves, balloons)?
  • Aspirin?
  • Ibuprofen (Motrin, Advil)?
  • Penicillin?
  • Other antibiotics?
  • Metals (jewelry, clothing snaps)?
  • Acrylics?
  • Plant pollens?
  • Animals?
  • Foods?
  • Other substances?

  • PATIENT HEALTH INFORMATION

    List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
  • Women: Are you pregnant?
  • Are you trying to become pregnant?

  • FAMILY MEDICAL HISTORY

    Have your parents or siblings ever had any of the following health problems? If so, please explain.

  • RELEASE AND WAIVER

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

  • Date*
     - -
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  • Should be Empty: