Health History for Adult
Patient Biographical Information
Title:
Mr.
Ms.
Mrs.
Dr.
Prof.
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Male
Female
Other
Address:
City:
State:
Zip:
*
Primary Phone:
Home
Cell
Work
Phone 2:
Home
Cell
Work
Email:
How would you like to receive reminders?
Email
Text
Both
None
Please list the names of any friends or family currently in the practice?
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Email:
Address:
City:
State:
Zip:
*
Primary Phone:
Home
Cell
Work
Phone 2:
Home
Cell
Work
Employer:
Occupation:
Work Phone:
Dental History
Dentist Name:
Last Dental Visit:
Checkup Frequency:
Once per year
Twice per year
More than twice per year
Never
Emergencies only
How many times a month do you floss?
Have you had an orthodontic consult or treatment?
No
Yes
If so, when?
Please describe your main reason for seeking/considering orthodontic treatment:
What concerns you most about having orthodontic treatment?
Appearance
Cost
Discomfort
Success
Duration of Treatment
Any other concerns?
Do you need to premedicate prior to dental visits?
No
Yes
Please select 'Yes' if you have or had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems or therapy?
No
Yes
Clench or grind teeth?
No
Yes
Injury to face, jaw, teeth, or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness, or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
*
Oral habits (thumb/finger sucking)?
No
Yes
If so, until what age?
*
Other Oral habits (lip/nail biting, etc)?
No
Yes
Neck or shoulder pain?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires Antibiotic Premedication?
No
Yes
Missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Date of Last Physical:
Patient Health:
Good
Excellent
Fair
Poor
Physician's Address:
City:
State:
Zip:
Please list any medications you are currently taking:
Please list any food or drug allergies/sensitivities:
Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Rheumatic fever?
No
Yes
Tuberculosis or lung disease?
No
Yes
Pneumonia?
No
Yes
Liver disease?
No
Yes
Kidney disease?
No
Yes
Heart attack or stroke?
No
Yes
Heart disease?
No
Yes
Heart defect (congenital)?
No
Yes
Heart murmur?
No
Yes
Hemophilia?
No
Yes
High blood pressure or hypertension?
No
Yes
Prolonged bleeding or transfusion?
No
Yes
Anemia or blood disorder?
No
Yes
HIV or AIDS?
No
Yes
Hepatitis?
No
Yes
Tonsils or adenoids removed?
No
Yes
Cancer?
No
Yes
Family history of oral cancer?
No
Yes
Received radiation treatment?
No
Yes
Growth problems?
No
Yes
Endocrine problems?
No
Yes
Hormone therapy?
No
Yes
Latex Allergy
No
Yes
Nervous disorders?
No
Yes
Bone disorders or loss?
No
Yes
Diabetes?
No
Yes
Seizures/epilepsy?
No
Yes
Handicaps or disabilities?
No
Yes
Asthma?
No
Yes
Arthritis?
No
Yes
Treated for emotional problems?
No
Yes
Ever been hospitalized?
No
Yes
Metal Allergy
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
E-Signature of Patient:
Date