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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 Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
RESPONSIBLE PARTY
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to patient
Occupation
Responsible Party Social Security #
SPOUSE INFORMATION
Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Gender
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Relationship to patient
Occupation
Social Security #
DENTAL INSURANCE INFORMATION
Policy Holder’s Name
*
Employer
*
Policy Holder’s Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Company
*
Group #
*
Patient ID or Social Security #
*
EMERGENCY CONTACT INFORMATION
Emergency Contact Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to patient
*
DENTAL HISTORY
Current Dentist
Date of Last Visit
-
Month
-
Day
Year
Date
Current on dental work
*
Yes
No
Main Orthodontic Concern
*
Referred by
*
Have you seen an Orthodontist or had Orthodontic treatment before?
*
Yes
No
Who?
Where?
Dental History
*
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
*
-
Month
-
Day
Year
Date
Patient Health
*
Good
Fair
Poor
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
*
Medical History
*
Rows
Yes
Satisfied
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
Signature
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
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