Dental History Form for Adult Patients

Dental History Form for Adult Patients
Patient Info
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Title*
I prefer to be called (if Other)
Birth date*

MonthDayYear
Date
Social Security #*
What sex was the patient assigned on their birth certificate?*
What is the patient’s current gender identification?*
What are the patient’s preferred pronouns?
Marital Status*
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home phone
Please enter a valid phone number.Format: (000) 000-0000.
Work phone
Please enter a valid phone number.Format: (000) 000-0000.
E-mail address*
example@example.com
Occupation
Employer
Closest Relative
Spouse or closest relative’s name*

First NameLast Name
Relationship to patient*
Title: Closest relative*
Prefer to be called (Closest relative, if Other)
Closest relative address (if different than patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Closest relative cell phone*
Please enter a valid phone number.Format: (000) 000-0000.
Closest relative home phone
Please enter a valid phone number.Format: (000) 000-0000.
Closest relative work phone
Please enter a valid phone number.Format: (000) 000-0000.
Dentist
Patient’s Dentist*

First NameLast Name
Address (Dentist)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last seen (Dentist)

MonthDayYear
Date
Reason (Dentist)
Next appointment (Dentist)

MonthDayYear
Date
Other dentists/dental specialists now being seen:

First NameLast Name
Address (Other dentists/dental specialists)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason (Other dentists/dental specialists)
Physician
Patient’s Physician*

First NameLast Name
Address (Patient’s Physician)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last seen (Patient’s Physician)

MonthDayYear
Date
General Information
What concerns you about your teeth?*
Who suggested that you might need orthodontic treatment?*
Why did you select our office?*
Have you had any previous orthodontic treatment? Please describe *
Have any other family members been treated in this office? Please name them.
Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.
Financial Responsibility
Who is financially responsible for this account?*

First NameLast Name
Address (if different from Patient Info section above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone (if different from Patient Info section above)
Please enter a valid phone number.Format: (000) 000-0000.
Home phone (if different from Patient Info section above)
Please enter a valid phone number.Format: (000) 000-0000.
Email (if different from Patient Info section above)
example@example.com
Social Security # (if different from Patient Info section above)
Employer (if different from Patient Info section above)
Dental Insurance
Primary policy holder’s full name

First NameLast Name
Birth date (Primary policy holder)

MonthDayYear
Date
Social Security # (Primary policy holder)
Relationship to patient (Primary policy holder)
Address (if not listed above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone (if not listed above)
Please enter a valid phone number.Format: (000) 000-0000.
Insurance company (Primary policy holder)
Group # (Primary policy holder)
ID # (Primary policy holder)
Does this policy have orthodontic benets? (Primary policy holder)
Secondary policy holder’s full name

First NameLast Name
Birth date (Secondary policy holder)

MonthDayYear
Date
Social Security # (Secondary policy holder)
Relationship to patient (Secondary policy holder)
Address (Secondary policy holder)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Secondary policy holder)
Please enter a valid phone number.Format: (000) 000-0000.
Employer (Secondary policy holder)
Insurance company (Secondary policy holder)
Group # (Secondary policy holder)
ID # (Secondary policy holder)
Does this policy have orthodontic benets? (Secondary policy holder)
Medical Insurance
Policy holder’s full name (Medical Insurance)

First NameLast Name
Insurance company (Medical Insurance)
Patient Health Information
Do you take antibiotic pre-medication before any dental procedures?

YesNo
Has the patient ever taken any medications to strengthen their bones? Please describe.
Does the patient currently have (or ever had) a substance abuse problem?
Does the patient currently suffer with, or have suffered in the past with an eating disorder?
Does the patient chew or smoke tobacco?

YesNo
If yes, what is the frequency?
Have you noticed any changes in the patient’s face or jaws?
Is the patient pregnant?

YesNo
Is the patient trying to become pregnant?

YesNo
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for
Medication
Taken for
Medication
Taken for
Medication
Taken for
Dental History
How often do you brush?
How often do you floss?
Now or in the past, have you had:

Permanent or extra (supernumerary) teeth removed?Supernumerary (extra) or congenitally missing teeth?Chipped or injured primary or permanent teeth?Any sensitive or sore teeth?Bleeding gums, bad taste or mouth odor?Jaw fractures, cysts, infections?Any teeth treated with root canals or pulpotomies?“Gum boils,” frequent canker sores or cold sores?History of speech problems or speech therapy?Difficulty breathing through nose?Food impaction between the teeth?Mouth breathing habit or snoring at night?History of speech problems?Frequent oral habits (sucking finger, chewing pen, etc.)?Teeth causing irritation to lip, cheek or gums?Abnormal swallowing (tongue thrust)?Clicking, locking in jaw joints?Soreness in jaw muscles or face muscles?Ringing in ears, difficulty in chewing or opening jaw?Have you ever been treated for “TMJ” or “TMD” problems?Any broken or missing fillings?Any serious trouble associated with previous dental treatment?Have you ever been diagnosed with gum disease or pyorrhea?Have you ever had an orthodontic consultation or treatment before now?
Medical History
Now or in the past, have you had:

Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates, Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?Hereditary or developmental conditions?Bone fractures, or major injuries?Any injuries to face, head, neck?Arthritis or joint problems?Endocrine or thyroid problems?Diabetes or low sugar?Kidney problems?Cancer, tumor, radiation treatment or chemotherapy?Stomach ulcer, hyperacidity, acid reflux?Immune system problems?History of osteoporosis?Gonorrhea, syphilis, herpes, sexually transmitted diseases?AIDS or HIV positive?Hepatitis, jaundice or other liver problem?Polio, mononucleosis, tuberculosis, pneumonia?Seizures, fainting spells, neurologic problems?Mental health disturbance or depression?Vision, hearing, or speech problems?History of eating disorders (anorexia, bulimia)?Have you experienced any weight change in the past several months?High or low blood pressure?Excessive bleeding or bruising, anemia?Chest pain, shortness of breath, tire easily, swollen ankles?Heart defects, heart murmur, rheumatic heart disease?Angina, arteriosclerosis, stroke or heart attack?Skin disorder (other than common acne)?Do you eat a well-balanced diet?Frequent headaches or migraines?Frequent ear infections, colds, throat infections?Asthma, sinus problems, hayfever?Tonsil or adenoid condition?Do you frequently breathe through your mouth?
Have you had allergies or reactions to any of the following:

Latex (gloves, balloons)Metals (jewelry, clothing snaps)AcrylicsLocal anesthetics (novocaine, lidocaine, xylocaine)AspirinIbuprofen (Motrin, Advil)PenicillinOther antibioticsPlant pollens
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
Motivation for treatment

Patients often request changes in their bites or faces and relief from pain or discomfort. Please help us understand your problem by checking the following information; please be specific (circle the words more, less, forward, backward, longer, shorter, etc.)
Teeth

If your teeth could be changed, how would you like them to change?
Straighten teeth

Straighten the front teeth (upper)Straighten the front teeth (lower)Straighten the back teeth (upper)Straighten the back teeth (lower)
Move teeth

Make the upper front teeth longerMake the upper front teeth shorterMove upper teeth forwardMove upper teeth backwardMove lower teeth forwardMove lower teeth backwardMake the line of the upper front teeth more level
Other teeth changes
Face
If your facial appearance could be changed, what would you change?

Get rid of sag under lower jawMove chin forwardMove chin backwardMove chin left/right to center itMove lower lip forwardMove lower lip backwardMove upper lip forwardMove upper lip backwardMove the area around the nose forwardMove the area around the nose backwardMake the profile of my nose longerMake the profile of my nose shorterMove the area under my eyes forwardMove the area under my eyes backwardMake the cheekbones largerMake the cheekbones smallerShow more of my teeth when I smileShow less of my teeth when I smileShow more of my gums when I smileShow less of my gums when I smileMake my lips closer together when my teeth are touchingMake my lips farther apart when my teeth are touchingMake my lips not touch and roll out when my teeth are touchingReduce the strain in my chin when I close my lipsReduce the strain in my lips when I close my lipsMake my face more narrowMake my face more wideReduce the width of my lower jaw behind my mouthReduce the fullness of my lower jaw behind my mouthOther
Symptoms
If you want to reduce pain or discomfort where would it be located? Please be specific about the location; choose the right side, left side, or both if they apply.

In front of my right earIn front of my left earBelow my right earBelow my left earAbove my right earAbove my left earIn my right earIn my left earRight shoulderLeft shoulderRight templeLeft templeRight eyeLeft eyeTeethSinusesOther
Consent
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent.

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
Release and Waiver
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. *
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.*
Today's Date*

MonthDayYear
Date
Medical History Updates or Changes
Changes
Patient Signature
Patient Signature Date

MonthDayYear
Date
Dental Staff Signature
Dental Staff Signature Date

MonthDayYear
Date
Should be Empty:

Dental History Form for Adult Patients

Patient Info

Closest Relative

Dentist

Physician

General Information

Financial Responsibility

Dental Insurance

Medical Insurance

Patient Health Information

Dental History

Medical History

Family Medical History

Motivation for treatment

Teeth

Face

Symptoms

Consent

Release and Waiver

Medical History Updates or Changes