Henry Advanced Orthodontics - Adult Health History Form

Adult Patient Health Record
Name

First NameLast Name
Select One

MalesFemale
Date of Birth

MonthDayYear
Date
Age
Home Phone
Please enter a valid phone number.
Cell/Other
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have Orthodontic Insurance Coverage, please fill out below:
Insurance Company Name
Group # (Plan, Local or Policy)
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse
Name

First NameLast Name
Select One

MalesFemale
Date of Birth

MonthDayYear
Date
Age
Home Phone
Please enter a valid phone number.
Cell/Other
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Ext.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If your spouse has Orthodontic Insurance Coverage, please fill out below:
Insurance Company Name
Group # (Plan, Local or Policy)
ID #
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I herby authorize the release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.
Signature

Clear
Date

MonthDayYear
Date
What is Your Primary Concern
Dental History

Now or in the past, have you had:

	Yes	No	dk/u
Permanent or "Extra" (Supernumerary) Teeth Removed?
Chipped or Injured Primary (Baby) / Permanent Teeth?
Bleeding Gums, Bad Taste or Mouth Odor?
Periodontal "Gum" Problems/Treatment?
Mouth Breathing Habit, Snoring or Difficulty in Breathing?
Tooth Grinding, Jaw Clenching, Clicking or Locking?
Any Pain in Jaw or Ringing in the Ears?
Any pain or Soreness in the Muscles of the Face or Around the Ears?
Difficulty Encountered in Chewing or Jaw Opening?
Aware or Concerned about Under or Over-Developed Jaw?
Any Relative with Similar Tooth of Jaw Relationships?
Ever Had a Prior Orthodontics Examination or Treatment?

I understand that the information I have given is correct to the best of my knowledge, that it will be help in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental/orthodontic services I may need.
Signature

Clear
Date

MonthDayYear
Date

Now of in the past, have you had:

	Yes	No	dk/u
Abnormal Blood Pressure (High or Low)
AIDS, ARC, HIV Positive or Other STD
Allergies or Hives - Hay Fever, Asthma, Sinus Trouble
Anemia, Excessive Bleeding or Bruising Tendency
Anorexia or Bulimia
Arthritis or Rheumatoid Conditions
Artificial Heart Valve(s)/Bones/Joints
Asthma
Birth Defects or Hereditary Problems
Bleeding Disorders or Taking Blood Thinners
Blood Transfusions
Bone Fractures or Any Major Accidents
Cancer or Tumor/Chemo/Radiation Treatments
Cankers or Cold Sores (Mouth or Body)
Chest Pain, Shortness of Breath or Swelling Ankles
Congenital Heart Defect(s)
Diabetes
Epilepsy, Seizures or Convulsions
Eye, Ear, Nose or Throat Condition
Fainting or Dizzy Spells
Frequent Headaches, Colds or Sore Throat
Glaucoma

Now of in the past, have you had:

	Yes	No	dk/u
Handicapped or Disabled
Heart Disease or Attack
Heart Murmur (e.g. Mitral Valve Prolapse)
Hepatitis (A, B or C)
Herpes
High or Low Blood Pressure
Implant (Joint, Eye, Breast, or Other)
Immune System Conditions
Jaundice or Other Liver Disorder
Kidney Disease
Mental Health, Behavioral Problems or Depression
Organ Transplant
Rheumatic Fever
Sickle Cell Anemia
Stomach Ulcer or Hyperacidity
Thyroid Disease or Endocrine Problems
Tonsil or Adenoid Conditions
Tuberculosis (TB)
Ulcers (Stomach, Intestine, Mouth)
Vision, Hearing, Tasting or Speech Difficulties
Weight Loss (Recent) or Poor Appetite?

Are there any other Medical Conditions that We should be Aware of?

Allergies or Reactions to any of the following:

	Yes	No	dk/u
Local Anesthetics (Novocaine or Lidocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin or Other Antibiotics
Sulfa Drugs
Codeine or Other Narcotics
Metals (Jewelry, Clothing Snaps)
Acrylic
Latex (Gloves, Balloons)
Vinyl
Are you taking Medications, Nutritional Supplements, Herbal medications or Non-Prescription Medicines?

Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Medication:
Taken For:
Do you have or ever had a Substance Abuse Problem?

YesNodk/u
Do you chew or Smoke Tobacco?

YesNodk/u
Operations?

YesNodk/u
Describe:
Hospitalized?

YesNodk/u
For:
Other Physical Problems or Symptoms?

YesNodk/u
Describe:
Being Treated by Another Health Care Professional?

YesNodk/u
For:
Date of Most Recent Physical Exam:

MonthDayYear
Date
Have you ever taken Bisphosphonates or Any Other Drug for Osteoporosis/Osteopenia?

YesNodk/u
Describe:

Females Only:

	Yes	No	dk/u
Are you taking Birth Control?
Are you taking Hormones?
Are you Pregnant?
Are you Nursing?

Family Medical History

Do Your Parents or Siblings Have Any of the Following Health Problems? If so, Please Explain:

	Yes	No	dk/u
Bleeding Disorders
Diabetes
Arthritis
Metabolic Disturbances
Severe Allergies
Unusual Dental Problems
Jaw Size Imbalance

Another Other Medical Conditions That We Should Know About?

YesNodk/u
Describe
What other disease, condition, or problem do you have that is not previously listed?
I certify that the above information is correct to the best of my knowledge. I understand I must notify Dr. Chris Henry and/or her staff immediately at any time my information changes.
Signature

Clear
Date

MonthDayYear
Date
I authorize the release of medical/dental information to any of the following if needed: My physician, any other physician or other dental offices I may be referred to, attorneys (with my prior release by signature), and my insurance company.
Signature

Clear
Date

MonthDayYear
Date
I understand Dr. Chris Henry may photograph my face and mouth for the purpose of documentation in my record. blanks (initial). I further understand and grant my permission to Dr. Chris Henry to use my photographs for educating other patients, prospective patients or other health care professionals, which may include but not be limited to, inclusion on Dr. Chris Henry's website, office photographs or video.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Adult Patient Health Record

Spouse

Dental History

Family Medical History