Stewart Family Orthodontics Health History

ADULT PATIENT HEALTH HISTORY INFORMATION
Patient's Name*

First NameLast Name
Preferred Name*
Gender*

MaleFemale
Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address (Responsible Party)*
example@example.com
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Mobile Phone #*
Please enter a valid phone number.Format: (000) 000-0000.
Other family members seen by us
Spouse or significant other contact name

First NameLast Name
Contact's Phone #
Please enter a valid phone number.Format: (000) 000-0000.
If you were referred to our office, please let us know who referred you.
Name of General Dentist

First NameLast Name
Dentist's Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Date. of Last Exam

MonthDayYear
Date
Name of Family Physician

First NameLast Name
Physician's Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Exam

MonthDayYear
Date
May we contact you using ....? (check all that apply)

TextEmailMobile
Marital status

SingleMarriedDivorcedWidowed
Insurance Information
Do you have dental insurance that includes an adult orthodontic benefit?*

YesNo
If yes, then please complete the following:
Primary Coverage
Policy Holder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Employer
Social Security Number
Insurance Carrier
Group #
Policy #
Carrier Phone # (if you'd like us to check on your behalf)
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Coverage
Do you have dental insurance that has an adult orthodontic benefit?

YesNo
If yes, please complete the following:
Policy Holder's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Employer
Social Security Number
Insurance Carrier
Group #
Policy #
Carrier Phone # (if you'd like us to check on your behalf)
Please enter a valid phone number.Format: (000) 000-0000.
Medical History

The following information is required to enable us to provide you with the best possible care. All information is strictly private and is protected by doctor-patient confidentiality. The orthodontist will review your medical history and explain any questions that you do not understand.
Are you being treated for any medical condition at this time or have you been treated for a medical condition within the past two years?*

YesNo
If yes, please explain:
Has there been a change in your health within the past two years?*

YesNo
If yes, please explain:
Are you currently taking any medications, non-prescription drugs, or herbal supplements?*

YesNo
If yes, please explain:
Do you have any allergies? If yes, please explain using the categories below:*

YesNo
a) Medications
b) Latex and/or rubber products
c) Other (e.g. foods, hayfever, etc.)
Have you had your adenoids and/or tonsils removed?*

YesNo
Do you have any conditions or therapies that could affect your immune system (e.g. leukemia, AIDS, HIV, radiotherapy, chemotherapy)?

YesNo
Have you ever been hospitalized for any illnesses or operations?

YesNo
If yes, please explain:
Have you ever been treated by a physician for (check all that apply):
Do you have any other medical conditions?

YesNo
If yes, please explain:
Women: Are you breastfeeding or pregnant?

YesNo
If pregnant, what is the due date?

MonthDayYear
Date
Dental History
What concerns do you have about your teeth/smile?*
Are you nervous during dental treatment?*

YesNo
Are you a mouth-breather while sleeping or awake (or both)?*

YesNo
Have you ever had a habit such as thumb or finger sucking, nail biting, lip sucking, grinding teeth, or an unusual swallow pattern?*

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

YesNo
Have you experienced any jaw joint noises, pain, or limited movement?*

YesNo
Have you previously consulted an orthodontist?*

YesNo
Has any member of your family had orthodontic treatment?*

YesNo
Have you ever experienced any complications following dental treatment?*

YesNo
Are you currently having any dental treatment?*

YesNo
Have you had a cavity in the last year?*

YesNo
Have you ever been told that you had periodontal (gum) disease?*

YesNo
Have you ever been told that you had bone loss around your teeth?*

YesNo
Do your gums bleed when brushed?*

YesNo
Have you ever injured your teeth?*

YesNo
Have you ever injured your jaws or face?*

YesNo
Have you ever had problems with your jaw joints (TMJD)?*

YesNo
Patient Consent

Privacy of your personal health information is an important part of our office's providing you with quality dental care. We understand the importance of protecting your personal health information. We are committed to collecting, using and disclosing your personal health information responsibly. We also try to be as open and transparent as possible about the way we handle your personal health information. It is important to us to provide this service to our patients. In this office, Dr. Daniel Stewart is the contact person for personal health information related matters. All staff members who come into contact with your personal health information are aware of the sensitive nature of the information that you have disclosed to us. They are all trained in the appropriate uses and protection of your information.
- Only necessary information is collected about you.
- We only share your information with your consent.
- Storage, retention and destruction of your personal health information complies with existing legislation, and privacy protection protocols.
- Our privacy protocols comply with ADA standards.
Do not hesitate to discuss our policies with Dr. Stewart or any member of our office staff. By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal health information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal health information, we will seek your approval in advance.
AUTHORIZATION
To the best of my knowledge, the above information is correct. If there is a change in my health history, or my medications change, I will inform the orthodontist at the next appointment.*

Agree
When appropriate or necessary, the orthodontist may send and discuss my health information with other involved health professionals.*

Agree
Form Submission Date*

MonthDayYear
Date
Signature*
Additional Comments/Notes
Should be Empty:

ADULT PATIENT HEALTH HISTORY INFORMATION

Insurance Information

If yes, then please complete the following:

Primary Coverage

Secondary Coverage

If yes, please complete the following:

Medical History

Dental History

Patient Consent

AUTHORIZATION