Health History Form

Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you.
PATIENT INFORMATION
Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
RESPONSIBLE PARTY
Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
Occupation
SSN
SPOUSE INFORMATION
Name

First NameMiddle NameLast Name
Birthdate

MonthDayYear
Date
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Relationship to Patient
Occupation
SSN
DENTAL INSURANCE INFORMATION
Policy Holder’s Name:

First NameLast Name
Employer
Policy Holder’s Date of Birth

MonthDayYear
Date
Insurance Company
Group #
Patient ID or Social Security #
EMERGENCY CONTACT INFORMATION
Emergency Contact Name

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to patient:
DENTAL HISTORY
Current Dentist:
Date of Last Visit:
YesNo
Main Orthodontic Concern:
Referred by:
YesNo
Who?
Where?

Rows	Yes	No
Speech problem/therapy
Grind or clench teeth
Oral habits (thumb/finger habit, lip/nail biting)
Injury to face, jaw, teeth or mouth
Discomfort from teeth or gums
Pain, tenderness, or noise in jaw
Frequent headaches
Neck/Shoulder pain
Frequent sore throats
Chipped or injured permanent teeth
Teeth sensitive to hot or cold
Previous root canal therapy
Bad taste/ mouth odor
Abnormal swallowing (Tongue thrust)
Teeth that irritate tongue, cheek, lip
Brush teeth daily
Floss daily
Fluoride treatments
Mouth breathing
Snores during sleep
Any missing or extra permanent teeth
Apprehensive about dental care
Frequently chews gum
Thumb or finger habit as a child
Jaw fractures, cysts, mouth infections
Bleeding gums
Periodontal (gum) problems
Frequent canker sores or cold sores
Problems with food trapped between teeth
Had a TMJ screening

MEDICAL HISTORY
Physician Name:
Date of last physical:
GoodFairPoor
Any changes in the patient’s general health within the last year?
Is the patient under care of a physician? If so, what for?
Has the patient had a serious illness/ hospitalization in the past 5 years?
Current Medications
Allergies or drug reactions

Rows	Yes	No
Latex
Sulfa Drugs
Local anesthetics
Other
Heart Murmur
Congenital Heart Defect
Rheumatic Fever
Diabetes
Growth Problems
Hemophilia
Prolonged Bleeding/Transfusion
HIV/AIDS
Asthma
Pregnant
Thyroid/ Endocrine problems
Penicillin or other antibiotics
Aspirin, Ibuprofen, Tylenol
Codeine or other narcotics
Tuberculosis/Lung Disease
Cancer
Angina
Liver Disease
Kidney Disease
Heart attack/stroke
Hypertension/High blood pressure
Anemia/ blood disorder
Seizures/Epilepsy
Low blood pressure
Taking Bisphosphonates(Fosamax, Boniva)
Chronic fatigue

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Signature
Date

MonthDayYear
Date
Should be Empty:

Health History Form

PATIENT INFORMATION

RESPONSIBLE PARTY

SPOUSE INFORMATION

DENTAL INSURANCE INFORMATION

EMERGENCY CONTACT INFORMATION

DENTAL HISTORY

MEDICAL HISTORY