Adult Health History Form

Patient

Date

Patient's last name

First name

Middle initial

Title

I prefer to be called:

Other (Title)

Birth date

Gender

Male

Female

Social Security #

Home address

City

State

Zip

Home phone

Cell phone

Work phone

Email address(es)

Occupation

Employer

Close Relative

Spouse or closest relatives name(s)

Title

Relationship to patient

Other (Title)

Address (if different than patient address)

City

State

Zip

Home phone (if different)

Cell phone

Work phone

Dentist

Patient's dentist

Address

City

State

Zip

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen: Name

Address

City

State

Zip

Reason

Physician

Patient's Physician

Address

City

State

Zip

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now

Name

Address

City

State

Zip

Reason

Name

Address

City

State

Zip

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 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?

Address (if different from above)

City

State

Zip

Home phone

Cell phone

Email

Social Security #

Employer

Dental Insurance

Primary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Inurance company

Group #

ID#

Does this policy have orthodontic benefits?

Yes

No

I don't know

Secondary policy holder's full name

Birth date

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Inurance company

Group #

ID#

Does this policy have orthodontic benefits?

Yes

No

I don't know

Medical Insurance

Policy holder's full name

Insurance Company

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u).

Now or in the past, have you had:

Birth defects or hereditry problems?

No

Yes

Bone fractures or major injuries?

No

Yes

Any injuries to face, head, neck?

No

Yes

Arthritis or joint problems?

No

Yes

Endocrine or thyroid problems?

No

Yes

Diabetes or low blood sugar?

No

Yes

Kidney problems?

No

Yes

Cancer, tumor, radiation treatment or chemotherapy?

No

Yes

Stomach ulcer, hyperacidity, acid reflux?

No

Yes

Immune system problems?

No

Yes

History of osteoporosis?

No

Yes

Gonorrhea, syphilis, herpes, sexually transmitted diseases?

No

Yes

AIDS or HIV positive?

No

Yes

Hepatitis, jaundice, or any other liver problems?

No

Yes

Polio, mononucleosis, tuberculosis, or pneumonia?

No

Yes

Seizures, fainting spells, neurolgic problems?

No

Yes

Mental health disturbance or depression?

No

Yes

Vision, hearing or speech problems?

No

Yes

History of eating disorder (anorexia, bulimia)?

No

Yes

High or low blood pressure?

No

Yes

Excessive bleeding or bruising, anemia?

No

Yes

Chest pain, shortness of breathe, tire easily, swollen ankles?

No

Yes

Heart defects, heart murmur, rheumatic heart disease?

No

Yes

Angina, arteriosclerosis, stroke or heart attack?

No

Yes

Skin disorder (other than common acne)?

No

Yes

Do you eat a well-balanced diet?

No

Yes

Frequent headaches or migraines?

No

Yes

Frequent ear infections, cold, throat infections?

No

Yes

Asthma, sinus problems, hayfever?

No

Yes

Tonsil or adenoid condition?

No

Yes

Do you frequently breathe through your mouth?

No

Yes

Have you had allergies or reactions to any of the following?

Local anesthetics (novocaine, lidocaine, xylocaine)

No

Yes

Latex (gloves, balloons)

No

Yes

Asprin

No

Yes

Metals (jewelry, clothing snaps)

No

Yes

Penecillin

No

Yes

Other antibiotics

No

Yes

Ibuprofen (Motrin, Advil)

No

Yes

Acrylics

No

Yes

Plant pollens

No

Yes

Animals

No

Yes

Foods

No

Yes

Other substances

No

Yes

Other

Dental History

Now or in the past, have you had?

Permanent or extra (supernumerary) teeth removed?

No

Yes

Supernumerary (extra) or congenitally missing teeth?

No

Yes

Chipped or injured primary or permanant teeth?

No

Yes

Any sensitive or sore teeth?

No

Yes

Bleeding gums, bad taste or mouth odor?

No

Yes

Jaw fractures, cysts, infections?

No

Yes

Any teeth treated with root canals or pulpotomies?

No

Yes

Gum boils, frequent canker sores or cold sores?

No

Yes

History of speech problems or speech therapy?

No

Yes

Difficulty breathing through nose?

No

Yes

Food impaction between the teeth?

No

Yes

Mouth breathing habit or snoring at night?

No

Yes

Frequent oral habits(sucking finger, chewing pen, etc)?

No

Yes

Teeth causing irritation to lip, cheek or gums?

No

Yes

Abnormal swallowing (tongue thrust)?

No

Yes

Tooth grinding or clenching?

No

Yes

Clicking, locking in jaw joints?

No

Yes

Soreness in jaw muscles or face muscles?

No

Yes

Ringing in ears, difficulty in chewing or opening jaw?

No

Yes

Have you ever been treated for TMU or TMD problems?

No

Yes

Any broken or missing fillings?

No

Yes

Any serious trouble associated with previous dental treatment?

No

Yes

Have you ever been diagnosed with gum disease or pyorrhea?

No

Yes

Have you ever had an orthodontic consultation or treatment before now?

No

Yes

Patient Health Information

Now or in the past, have you had?

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe.

Do you take antibiotic pre-medication before any dental procedures?

Do you or have you ever had a substance abuse problem?

Do you chew or smoke tobacco?

Have you noticed any changes in your face or jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

Women: Are you pregnant

Yes

No

Are you trying to become pregnant

Yes

No

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?

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

Medical History Updates or Changes

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date

Changes

Signature

Date

Dental Staff Signature

Date