• Medical Dental History Form for Adult Patients

    CONFIDENTIAL

  • PATIENT

  • Date*
     - -
  • Birth date*
     - -
  • What sex were you assigned on your birth certificate?*
  • What is your current gender identification?
  • Marital Status
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • CLOSEST RELATIVE

  • Title
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTIST

  • PHYSICIAN

  • Other physicians/health care providers being seen now:

  • GENERAL INFORMATION

  • FINANCIAL RESPONSIBILITY

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTAL INSURANCE

  • Does the Patient have 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 medical history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know understand (dk/u).

  • MEDICAL HISTORY

  • Rows
  • Rows

  • DENTAL HISTORY

  • Rows

  • PATIENT HEALTH INFORMATION

  • Do you take antibiotic pre-medication before any dental procedures?*
  • Have you ever taken any medications to strengthen your bones?*
  • Have you chewed tobacco?*
  • Smoked any substance or vaped?*
  • Have you noticed any changes in your face or jaws?*
  • 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?
  • Rows

  • 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*
     - -
  • Should be Empty: