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Download Medical Dental History Form for Adult Patients
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CONFIDENTIAL Medical Dental History Form for Adult Patients Patient Prefers to be called_____________________ Birth date _____________________ Marital Status oSingle oMarried Sex oMale oFemale oSeparated Social Security # __________________________________________________ oDivorced oWidowed Home Address_________________________________________________ Home Phone ( ) ________-_________ Cell Phone ( City, State, Zip Code _______________________________________ ) ________-__________ Work Phone ( ) ________-__________ Email Address(es) ________________________________________________________________________________________________________ Occupation________________________________________ Employer ___________________________________________________________ Emergency Contact Person ________________________________________________________ Phone Number ( ) ________-_________ Dentist Patient’s Dentist ______________________________________ Address, City, State ________________________________________________ Last Seen ____________________________________________ Reason ______________________________ Next Appointment __________ Other dentists/dental specialists now being seen: Name____________________________________ City, State __________________________ Reason _________________________________________________________________________________________________________________ Physician Patient’s Physician ____________________________________________ Last Seen ____________________________________________ City, State ________________________________________________ Reason ______________________________ Next Appointment __________ Most recent physical exam _________________________________________________________________________________________________ Other physicians/health care providers being seen now: Name_______________________________________________________ City, State ________________________________________________ Reason _________________________________________________________________________________________________________________ Name_______________________________________________________ City, State ________________________________________________ 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 other 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. _______________________________________ ________________________________________________________________________________________________________________________ Are you interested in accelerated treatment? oYes oNo Financial Responsibility Who is financially responsible for this account? ________________________________________________________________________________ Address (if different than page 1) _______________________________________________ City, State, Zip _________________________________ Home Phone ( ) ________-__________ Cell Phone ( Social Security # _______________________________ ) ________-__________ Email Address(es) _______________________________ Employer ________________________________________________________________ Dental Insurance Primary policy holder’s full name______________________________________________________________ Social Security # _______________________________ Birth Date__________________ Relationship to patient ____________________________________________________ Address and Phone (if not listed above) ______________________________________________________________________________________ Employer _____________________________________ Address_________________________________________________________________ Insurance Company ____________________________ Group # _______________________ Does this policy have orthodontic benefits? oYes oNo ID# ____________________________________ oDon’t Know Secondary policy holder’s full name____________________________________________________________ Social Security # _______________________________ Birth Date__________________ Relationship to patient ____________________________________________________ Address and Phone (if not listed above) ______________________________________________________________________________________ Employer _____________________________________ Address_________________________________________________________________ Insurance Company ____________________________ Group # _______________________ Does this policy have orthodontic benefits? oYes oNo ID# ____________________________________ oDon’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 following 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 YesNoDK/U ooo Birth defects or hereditary problems? oooSeizures, fainting spells, neurologic problems? ooo Bone fracture or major injuries? ooo Mental health disturbances or depression? ooo Any injuries to head, face, neck? ooo Vision, hearing, or speech problems? ooo Arthritis or joint problems? ooo History of eating disorder (anorexia, bulimia)? ooo Endocrine or thyroid problems? ooo High or low blood pressure? ooo Diabetes or low blood sugar? ooo Excessive bleeding, or bruising, anemia? ooo Kidney problems? ooo Chest pain, shortness of breath, tire easily, swollen ankles? ooo Cancer, tumor, radiation treatment or chemotherapy? ooo Heart defects, heart murmur, rheumatic heart disease? ooo Stomach ulcer, hyperacidity, acid reflux? ooo Angina, arteriosclerosis, stroke or heart attack? ooo Immune system problems? ooo Skin disorder (other than common acne)? ooo History of osteoporosis? ooo Frequent headaches or migraines? ooo Gonorrhea, syphilis, herpes, sexually transmitted diseases? ooo Frequent ear infections, colds, throat infections? ooo AIDS or HIV positive? ooo Asthma, sinus problems, hay fever? ooo Hepatitus, jaundice, or other liver problems? ooo Tonsil or adenoid condition? ooo Polio, mononucleosis, tuberculosis, pneumonia? ooo Does you frequently breathe through your mouth? Have you had allergies or reactions to any of the following? Yes No DK/U YesNoDK/U ooo Local anesthetics (novocaine, lidocaine, xylocaine) oooOther Antibiotics ooo Latex (gloves, balloons) ooo Ibuprofen (Motrin, Advil) oooAspirin oooAcrylics ooo Metals (jewelry, clothing snaps) oooAnimals oooPenicillin ooo Other substances ____________________________________________ Patient Health Information 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 ____________________________________________________ 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? oYes oNo Are you trying to get pregnant? oYes oNo 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 _____________________
