CONFIDENTIAL
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  • CONFIDENTIAL

    Medical Dental History Form for Adult Patients
  • Date*
     / /
  • Birth date*
     / /
  • What sex were you assigned on your birth certificate?*
  • What is your current gender identification?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Other dentists/dental specialists now being seen: 

  • Financial

  • Format: (000) 000-0000.

  • Dental Insurance

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

  • MEDICAL HISTORY

  • Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand dk/u

    Now or in the past, have you had:

  • Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?*
  • Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?*
  • Hereditary or developmental conditions?*
  • Bone fractures, or major injuries?*
  • Any injuries to face, head, neck?*
  • Arthritis or joint problems?*
  • Endocrine or thyroid problems?*
  • Diabetes or low 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?*

  • Have you had allergies or reactions to any of the following:

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

  • DENTAL HISTORY

  • 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 or speech therapy?*
  • 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 associated with previous dental treatment?*
  • Have you ever been diagnosed with gum disease or pyorrhea?*
  • Have you ever had an orthodontic consultation?*

  • PATIENT HEALTH INFORMATION

  • Do you take antibiotic pre-medication before any dental procedures?*

  • List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take. 

  • Have you chewed tobacco?*
  • Have you smoked any substance or vaped?*
  • 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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