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Adults_medical_history_final

CONFIDENTIAL
Medical Dental History Form
For Adult Patients
PATIENT
Patient’s last name _____________________ First name ________________________ Middle initial _____
Prefers to be called ___________________________ Birth date ____________________  Home address _____________________________________________________________________ _________________________________________________________________________________ Home phone _________________________________ Cell phone ___________________________________ Work phone __________________________________ Occupation _________________________________ Employer _______________________________ Email address _____________________________________________________________________
DENTIST
Dentist ____________________________________ Date last seen________________________________
Reason ______________________________________________________________________________ Other dentists/dental specialists now being seen: Name _________________________________________ Reason _______________________________________________________________________________
GENERAL INFORMATION
What concerns you about your teeth? _______________________________________________________
Who suggested that you might need orthodontic treatment? ______________________________________ How did you hear about our office? _________________________________________________________ In the past have you consulted with another orthodontist? £ Yes Name/Date _________________________________________ Have you had any previous orthodontic treatment? Please describe. _______________________________ ______________________________________________________________________________________ Orthodontist’s Name/Date __________________________________________ Have any other family members been treated in this office? Please name them. _____________________________________________________________________________________ CONFIDENTIAL
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account? ________________________________________________
Address (if different from Page 1) ___________________________________________________________ Home phone ________________________________ Cell phone __________________________________ Email address __________________________________________________
DENTAL INSURANCE
Primary policyholder’s
full name __________________________________________________________
Birth date ___________________________________ Social Security # _____________________________ Relationship to patient _________________________ Employer ___________________________________ Insurance company _________________________________________ Group # _________________________________ ID # _____________________________________ Insurance claim address __________________________________________________________________ Insurance phone number _____________________________________ Does this policy have orthodontic benefits? £ Yes Secondary policyholder’s full name _______________________________________________________
Birth date _____________________________ Social Security # _______________________ Relationship to patient _________________________ Employer ___________________________________ Insurance company _________________________________________ Group # __________________________________ ID # _____________________________________ Insurance claim address __________________________________________________________________ Insurance phone number _____________________________________ Does this policy have orthodontic benefits? £ Yes
PHYSICIAN
Physician’s name ______________________________________________________________________
Date last seen ________________________ Reason __________________________________________ Most recent Physical Exam ______________________ Other physicians/health care providers being seen now: Name _______________________________________ Reason __________________________________ CONFIDENTIAL

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 (DK).
Now or in the past have you had:
Yes No DK
Cancer, tumor, radiation treatment or chemotherapy? Stomach ulcer, hyperacidity, acid reflux? Gonorrhea, syphilis, herpes, sexually transmitted diseases? Hepatitis, jaundice or other liver problems? Polio, mononucleosis, tuberculosis, pneumonia? Seizures, fainting spell, neurologic problem? Mental health disturbance or depression? History of eating disorder (anorexia, bulimia)? Excessive bleeding or bruising tendency, anemia? Chest pain, shortness of breath, tire easily, swollen ankles? Heart defects, heart murmur, rheumatic heart disease? Angina, arteriosclerosis, stroke or heart attack? Frequent ear infections, colds, throat infections? Do you frequently breathe through your mouth? Have you ever taken intravenous bisphosphonates such as Zometa (zolendromic acid). Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? Have you ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders, osteoporosis or osteiopenia? CONFIDENTIAL
Have you ever had allergies or reactions to any of the following?
Yes No
Local anesthetics (novocaine, lidocaine, ect.)
Other allergies ______________________________________________________________________
DENTAL HISTORY
Now or in the past, have you had?
Yes No
Permanent or extra (supernumerary) teeth removed? Supernumerary (extra) or congenitally missing teeth? Chipped or injured primary or permanent teeth? Any teeth treated with root canals or pulpotomies? “Gum boils”, frequent canker sores or cold sores? History of speech problems or speech therapy? Mouth breathing habit or snoring at night? Frequent oral habits (sucking finger, chewing pen, etc.)? Teeth causing irritation to lip, cheek or gums? 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? Have you ever been told to take antibiotics before dental treatment. Any serious trouble associated with previous dental treatment? Have you ever been diagnosed with gum disease or pyorrhea? Have you noticed any unusual changes to your face or jaws?
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 ________________________________ Medication _______________________________ Taken for ________________________________ Medication _______________________________ Taken for ________________________________ CONFIDENTIAL
Have you ever taken any medications to strengthen your bones? If so please describe below. Please describe. _______________________________________________________________________ Do you currently have (or ever had) a substance abuse problem? £ Yes Does you chew or smoke tobacco? £ Yes £ No Any other physical problems? ___________________________________________________________ How often do you brush? ________________________ Floss?_________________________________ FAMILY MEDICAL HISTORY
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Yes No

RELEASE AND WAIVER
I authorize release of any information regarding my orthodontic treatment to my dentist/dental specialists
and dental 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 ________________

Source: http://www.caudillorthodontics.com/forms/AdultHealthHistoryForm.pdf

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