Adult Patient Health History
About You
Today's Date:
*
-
Month
-
Day
Year
Date
Name:
*
First Name
Last Name
I prefer to be called:
*
Gender
*
Male
Femail
Birthdate:
*
-
Month
-
Day
Year
Date
Age:
*
SSN:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status:
*
Single
Married
Divorced
Widowed
Separated
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Cell 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
Employer:
Employer's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How long there?
Occupation:
Where & when are best times to reach you?
Whom may we thank for referring you?
Children seen by us:
General Dentist:
Last Visit Date:
-
Month
-
Day
Year
Date
Spouse Information
His/Her Name
First Name
Last Name
Employer
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Person Responsible for Account
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relation:
Social Security Number:
Employer:
Orthodontic Insurance
Do you have orthodontic coverage?
*
Yes
No
Do you have dental coverage?
*
Yes
No
Insurance Company Name:
Insurance Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Group # (Plan, Local or Policy #):
Insured's Name:
First Name
Last Name
Indured's Birthdate:
-
Month
-
Day
Year
Date
Insured's ID #:
Insured's Employer
Do you have secondary orthodontic coverage?
*
Yes
No
Do you have secondary dental coverage?
*
Yes
No
Insurance Company Name:
Insurance Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Group # (Plan, Local or Policy #)
Insured's Name:
First Name
Last Name
Relation:
Insured's Birthdate:
-
Month
-
Day
Year
Date
Insured's ID #:
Insured's Employer
Emergency Contact
In the event of an emergency, is there someone who lives near you we should contact?
His/Her Name:
First Name
Last Name
Relation:
Work Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Medical History
Do you have a personal physician?
Yes
No
Physician's Name:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Visit:
-
Month
-
Day
Year
Date
Medical History
Your current physical health is:
*
Good
Fair
Poor
Are you currently under the care of a physician?
*
Yes
No
If so, please explain:
Are you taking any prescription / over-the-counter drugs?
*
Yes
No
If so, please list them:
For Women: Are you using a prescribed method of birth control?
Yes
No
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding
Anemia
Artificial Bones / Joints / Valves
Asthma / Arthritis
Blood Transfusion
Cancer / Chemotherapy
Congenital Heart Defect
Diabetes
Difficulty Breathing
Drug / Alcohol Abuse
Emphysema
Epilepsy / Seizures / Fainting
Fever Blisters / Herpes
Glaucoma
Heart Attack / Stroke
Heart Murmur
Heart Surgery / Pacemaker
Hemophilia
Hepatitis
High / Low Blood Pressure
HIV+ / AIDS
Hospitalized for Any Reason
Kidney Problems
Mitral Valve Prolapse
Psychiatric Problems
Radiation Treatment
Rheumatic / Scarlet Fever
Severe / Frequent Headaches
Shingles
Sickle Cell Disease / Traits
Sinus Problems
Tuberculosis (TB)
Ulcers / Colitis
Venereal Disease
Please list any allergies you have:
Please list any serious medical condition(s) that you have ever had:
Are you allergic to any of the following?
Aspirin
Any Metals/Plastics
Codeine
Dental Anesthetics
Erythromycin
Latex
Penicillin
Tetracycline
Other
Please list any other drugs/materials that you are allergic to:
Dental History
Good Fair Poor What are the main concerns that you would like orthodontics to accomplish?
Have you ever had or been evaluated for orthodontic treatment? ☐
*
Yes
No
Have you ever had a serious / difficult problem associated with any previous dental work?
*
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ /TMD)?
*
Yes
No
Your current dental health is:
*
Good
Fair
Poor
Do you like your smile?
*
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any speech problems?
Do you generally breathe through your mouth?
*
Yes
No
If yes, when?
While Awake
While Asleep
Both
Do you have any missing or extra permanent teeth?
*
Yes
No
Have you ever taken Fosamax, or any other bisphosphonate?
*
Yes
No
Do you smoke or use tobacco in any form?
*
Yes
No
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
*
Date
*
-
Month
-
Day
Year
Date
If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for payment and co-payment anddeductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
*
Continue
Continue
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