Oasis Orthodontics - Health History Form

Health History Form

Would you please take a few minutes and complete our Patient History Form. Please be specific and complete with your answers, as this will aid us in providing the best care to you and your family. Thank you!
Patient's Name*

First NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
MaleFemaleN/A
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient attends school at
Other family members treated here
Parent / Guardian Information
MotherFatherGuardianOther
Name

First NameLast Name
Phone Number (If different than patient)
Please enter a valid phone number.Format: (000) 000-0000.
Address (If different than patient)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
S.S.N.
Email
example@example.com
Employer
Dental & Physician Information
Patient's Dentist*
Dentist Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Last Dentist Visit

MonthDayYear
Date
Physician's Name
Physician Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Last Physician Visit

MonthDayYear
Date
Insurance Information
YesNo
YesNo
Policy Holder 1
Policy Holder's Name

First NameLast Name
S.S.N.
Group #
Date of Birth

MonthDayYear
Date
Employed by
Policy I.D.
Insurance Company Name
Benefits Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Policy Holder 2
Policy Holder's Name

First NameLast Name
S.S.N.
Group #
Date of Birth

MonthDayYear
Date
Employed by
Policy I.D.
Insurance Company Name
Benefits Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For the following questions mark yes, no, or don’t know/understand (dk/u). The answers are for our records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Patient Profile*

Rows	Yes	No	DK/U
Does patient follow directions well?
Does patient brush his/her teeth conscientiously?
Does patient have learning disabilities?
Is patient sensitive or self-conscious about teeth?

Medical History*

Rows	Yes	No	DK/U
Birth defects or heredity problems?
Rheumatoid or arthritic conditions?
Diabetes?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer or hyperactivity?
Problems of the immune system?
AIDS or HIV positive?
Hepatitis, jaundice or liver problem?
Fainting spells, seizures?
Epilepsy or neurological problem?
Vision, hearing, tasting or speech difficulties?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Chest pain, shortness of breath or swelling ankles?
ANY cardiovascular problems (murmur, defects)?
Frequent headaches, colds or sore throats?
Hayfever, asthma, sinus trouble or hives?
Tonsil or adenoid conditions?
Does the patient chew or smoke tobacco?
Has the patient ever had a substance abuse problem?

Are there any medical conditions we should be aware of?
Is patient taking medication, nutrient supplements, herbal medications or non-prescription medicine? If yes, please list them.

Allergies*

Rows	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)
Latex (gloves, balloons)
Vinyl
Animals
Acrylic

Allergies to foods (specify)*
Allergies to other substances(specify)*

Dental History*

Rows	Yes	No	DK/U
Baby teeth removed that were not loose?
Permanent or "extra" teeth removed?
Congenitally missing teeth?
Chipped or injured permanent teeth?
Chipped or injured baby teeth?
Teeth sensitive to hot or cold; teeth throb or ache?
Jaw fractures, cysts or mouth infections?
"Dead teeth" or root canal treated teeth?
Bleeding gums, bad taste or mouth odor?
Periodontal "gum problems"?
Food impaction between teeth?
Thumb, finger or sucking habit?
Abnormal swallowing habit (tongue thrusting)?
History of speech problems?
Mouth breathing, snoring or difficulty breathing?
Tooth grinding or jaw clenching?
Any pain in jaw or ringing in ears?
Any pain in the muscles around the ears or face?
Difficulty in chewing or jaw opening?
Aware of loose, broken or missing restorations?
Any teeth irritating cheek, lip, tongue or palate?
Concerned about spaced, crooked or protruding teeth?
Frequent canker sores or cold sores?
Taking any forms of fluoride?
Any relative with similar tooth or jaw relation?
Had periodontal (gum) treatment?
Ever had a prior orthodontic examination?
Been under another dentist's care?

Would you object to wearing orthodontic appliances (braces) should they be indicated?
Any serious trouble associated with any previous dental treatment?

Girls Only*

Rows	Yes	No	DK/U
Has the patient started her monthly periods?
Is the patient pregnant?

Family Medical History*

Rows	Yes
Bleeding disorders
Diabetes
Arthritis
Metabolic disturbances
Severe allergies
Unusual dental problems
History of Underbite
Any other family medical conditions we should know about?

How often does your child brush?
How often does your child floss?
What is your primary concern?
How did you hear about Oasis?*
Signature
Date*

MonthDayYear
Date
Should be Empty:

Health History Form

Parent / Guardian Information

Dental & Physician Information

Insurance Information

Policy Holder 1

Policy Holder 2