Adult Medical & Dental History

Adult Medical & Dental History
Patient Information
Name

First NameLast Name
Today's Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age
D.O.B.

MonthDayYear
Date
Sex
Social Security #
Preferred Phone
Please enter a valid phone number.
HomeWorkCell
Secondary Phone
Please enter a valid phone number.
HomeWorkCell
Email
example@example.com
Emergency Contact Name

First NameLast Name
Relationship to Patient
Phone Number
Please enter a valid phone number.
Main Concerns
Why are you seeking orthodontic treatment?
Are you interested in...

Metal BracesClear BracesAligners/InvisalignOther
How did you hear about us?
Financial & Insurance Information
Primary Dental Insurance
Subscriber Name

First NameLast Name
Subscriber Social Security #
Subscriber D.O.B.

MonthDayYear
Date
Insurance Name
Insurance Phone
Please enter a valid phone number.
Subscriber/Member ID #
Group ID
Ortho Coverage?

YesNoNot Sure
Secondary Dental Insurance
Subscriber Name

First NameLast Name
Subscriber Social Security #
Subscriber D.O.B.

MonthDayYear
Date
Insurance Name
Insurance Phone
Please enter a valid phone number.
Subscriber/Member ID #
Group ID
Ortho Coverage?

YesNoNot Sure
RELEASE: I authorize the release of any information regarding my orthodontic treatment to my dental and/or medical insurance.
Patient Signature

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Date

MonthDayYear
Date
Dental History
Dentist Name
Location
City, State
Last Visit

MonthDayYear
Date
Reason for Last Visit
Have you ever had an orthodontic exam and evaluation?

YesNo

Have you experienced any of the following?

	Yes	No
Clenching/Grinding of Teeth
Thumb/Finger Sucking Habit
Tongue Thrust Habit
Tongue Tie
Lip or Cheek Biting Habit
Mouth Breathing or Trouble Breathing Through Nose
Unfavorable Reaction or Traumatic Dental Visit?
Unusual Change to Face or Bite
Snoring or Sleep Apnea
Injury to Mouth, Face, Teeth, or Chin
Speech Problems
Jaw Joint Problems or Soreness in TMJ
Chipped Teeth
Late Erupting or Missing Adult Teeth
Gum Disease
Previous Orthodontic Treatment

If Yes to any of the above questions, please elaborate:
Medical History
Physician Name
Location
City, State
Are you currently taking any medications?

YesNo
If Yes, please list the medications and for what conditions you take :
Please list any allergies (food, medicine, etc.):
Do you pre-medicate with antibiotics for dental procedures?

YesNo

Have you experienced any of the following?

	Yes	Any thoughts?
Allergy to Latex
Allergy to Metal
Allergy to Local Anesthetics (Lidocaine, Novocaine, etc.)
Cancer, Tumor, Radiation, or Chemotherapy
Skin Problems
Neurological Problems, Migraines, Seizures, Epilepsy
Eyes/Ears/Nose/Throat Problems
Tonsils/Adenoids Removed
Endocrine Problems, Diabetes, Thyroid Problems
Respiratory Problems, Asthma, Tuberculosis
Cardiovascular, Blood Pressure, or Heart Problems
Gastrointestinal/Liver Problems or Hepatitis
Kidney Problems
Musculoskeletal Problems, Arthritis, Injuries
Immunologic Problems, Influenza, HIV/AIDS
Herpes, Syphilis, Gonorrhea, Other STDs
Cleft Lip/Palate
Eating Disorders, Anorexia, Bulimia
Mental Health Problems or Depression

If Yes to any of the above questions, please elaborate:
Do you have any medical problems not listed above?
I have read the above questions and understand them. I will not hold my orthodontist or any member of 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 to my medical or dental health as they come.
Signature

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Date

MonthDayYear
Date
Should be Empty:

Adult Medical & Dental History

Patient Information

Main Concerns

Financial & Insurance Information

Primary Dental Insurance

Secondary Dental Insurance

Dental History

Medical History