Medical Dental History Form

Medical Dental History Form

for Adult Patients
Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Title

Mr.Mrs.Ms.Miss.Dr.Other
Birthday

MonthDayYear
Date
Social Security Number
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Occupation Employer
Closest Relative
Spouse or closest relatives name(s)
Title

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Dentist
Dentist Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Seen
Next Appointment
Reason
Other dentists/dental specialists now being seen:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason
Physcian
Patient’s Physician
City
State
Last Seen
Next Appointment
Reason
Most recent physical exam
Other physicians/health care providers being seen now:
Name
City and State
Reason
Name
City and 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 Responsibilty
Who is financially responsible for this account?
Address( If different from listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Email
example@example.com
Social Security Number
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
Dental Insurance
Insurance Company
Primary policy holder’s full name

First NameMiddle NameLast Name
Birthday

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company Group #
ID #
Does this policy have orthodontic benefits?

YesNoDon't Know
Secondary policy holder’s full name

First NameMiddle NameLast Name
Birthday

MonthDayYear
Date
Social Security Number
Relationship to Patient
Address(if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company Group #
ID #
Does this policy have orthodontic benefits?

YesNoDon't Know
Medical Insurance
Policy holder’s full name

First NameMiddle NameLast Name
Insurance Company

MEDICAL HISTORY Now or in the past, have you had:

	Yes	No	Don't Know
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 sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, STD?
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, swollen ankles?
Heart defects, heart murmur, rheumatic 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:

	Yes	No	Don't Know
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

DENTAL HISTORY Now or in the past, have you had:

	Yes	No	Don't Know
Permanent or extra teeth removed?
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 or cold sores?
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?

PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take and what they are 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?
Are you 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.
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MonthDayYear
Date
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staffresponsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontistof any changes in my medical or dental health.
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MonthDayYear
Date
Signature

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Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) requires that this office comply with certain rules regarding the maintenance of the privacy of your information that we have collected and will collect in the future.

This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices. Existing Michigan Law requires (in addition to our attempt to obtain your written acknowledgment, discussed above) us to first obtain your written consent prior to disclosing any of your information except for our disclosures in connection with: a defense to a claim challenging our
professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with your treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

Please sign this form below under the heading “acknowledgement” to acknowledge that you have today received a copy of our notice of privacy practices. I acknowledge that I have today received a copy of the Notice of Privacy Practices.
Parent/Guardian Signature

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List Patient Names
Date

MonthDayYear
Date
Patient Consent

Please sign this form below under the heading “consent” to consent to our disclosures of your information that we deem necessary in order to provide you with proper treatment.

I consent to your disclosures of my information, which you deem are necessary in connection with my treatment. I understand that such
disclosures may not be of the type listed above.
Parent/Guardian Signature

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List Patient Names
Date

MonthDayYear
Date
Should be Empty:

Medical Dental History Form

Closest Relative

Dentist

Physcian

General Information

Financial Responsibilty

Dental Insurance

Medical Insurance

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER