Health History Form - Adult Patients

Today's Date

Date

PATIENT

Patient's Name*

First NameLast Name

Title

I prefer to be called

Birth Date*

Date

Gender*

MaleFemale

Identify As*

MaleFemaleNon-binary

Social Security #

Marital Status

Home Address*

Street Address

apt or unit #

CityState / Province

Postal / Zip CodeCountry

Cell Phone Number*

Area CodePhone Number

E-mail*

Occupation*

Employer

CLOSEST RELATIVE

Spouse or Closest Relative*

Title

Home Address (if different from Patient's address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number (if different)

Area CodePhone Number

Cell Phone Number*

Area CodePhone Number

Work Phone Number

Area CodePhone Number

DENTIST

Patient's Dentist*

Phone Number*

Area CodePhone Number

Last Seen

Reason

Next Appointment

Other dentists/dental specialists now being seen:

Reason

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 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.

DENTAL INSURANCE

Do you have dental insurance?*

YesNo

Please attach copies of the FRONT and BACK of your dental insurance card

Browse Files

please attach 2 files - front and back

If you've attached pictures of the front and back of your insurance card, please include the subscriber's date of birth below.

If you do not have a copy of your dental insurance card, please fill out the information below. We will need every field completed in order to verify any coverage and benefits.

Primary Policy Holder's Full Name

First NameLast Name

Birth Date

Date

Social Security #

Relationship to Patient

Phone Number (if not listed above)

Area CodePhone Number

Employer

Insurance Company

Group #

ID #

Does this policy have orthodontic benefits?

YesNoDon't Know

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.

For the follow questions, please mark yes, no or don't know/understand (DK/U)

MEDICAL HISTORY

Now or in the past, have you had:*

	Yes	No	DK/U
Birth defects or hereditary problems
Bone fractures or major injuries?
Any injuries to face, head or 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 problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problems?
Mental health disturbance or depression?
Vision, hearing or speech problems?
History of eating disorder (anorexia, bulimia)?
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?*

	Yes	No	DK/U
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Aspirin
Metals (jewelry, clothing snaps)
Penicillin
Other antibiotics
Ibuprofen (Motrin, Advil)
Acrylics
Other substances (if yes, specify below)

If you checked 'Yes' for "Other substances", please specify below:

DENTAL HISTORY

Now or in the past, have you had:*

	Yes	No	DK/U
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?
Frequent oral habits (sucking finger, chewing pen, etc)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
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?

RELEASE AND WAIVER

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Signature*

Date

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.

Signature*

Date