Health History for Adult

Patient Biographical Information

Title:
First Name:
Middle Initial:
Last Name:
Nickname:
Birthdate:
Gender:
Address:
City:
State:
Zip:
* Primary Phone:
Phone 2:
Email:
How would you like to receive reminders?

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

First Name:
Middle Initial:
Last Name:
Birthdate:
Relationship to Patient:
Email:
Address:
City:
State:
Zip:
* Primary Phone:
Phone 2:
Employer:
Occupation:
Work Phone:

Dental History

Dentist Name:
Last Dental Visit:
Checkup Frequency:
How many times a month do you floss?
Have you had an orthodontic consult or treatment? If so, when?
Please describe your main reason for seeking/considering orthodontic treatment:
What concerns you most about having orthodontic treatment?
Any other concerns?
Do you need to premedicate prior to dental visits?

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?
Clench or grind teeth?
Injury to face, jaw, teeth, or mouth?
Discomfort from teeth or gums?
Pain, tenderness, or noise in either jaw?
Frequent headaches?
* Oral habits (thumb/finger sucking)?
If so, until what age?
* Other Oral habits (lip/nail biting, etc)?
Neck or shoulder pain?
Mouth breathing?
Snores during sleep?
Requires Antibiotic Premedication?
Missing or extra permanent teeth?
Apprehensive about dental care?
If any of the above dental questions were answered 'Yes', please explain:

Medical History

Physician Name:
Date of Last Physical:
Patient Health:
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?
Tuberculosis or lung disease?
Pneumonia?
Liver disease?
Kidney disease?
Heart attack or stroke?
Heart disease?
Heart defect (congenital)?
Heart murmur?
Hemophilia?
High blood pressure or hypertension?
Prolonged bleeding or transfusion?
Anemia or blood disorder?
HIV or AIDS?
Hepatitis?
Tonsils or adenoids removed?
Cancer?
Family history of oral cancer?
Received radiation treatment?
Growth problems?
Endocrine problems?
Hormone therapy?
Latex Allergy
Nervous disorders?
Bone disorders or loss?
Diabetes?
Seizures/epilepsy?
Handicaps or disabilities?
Asthma?
Arthritis?
Treated for emotional problems?
Ever been hospitalized?
Metal Allergy
If any of the above medical questions were answered 'Yes' , please explain:
E-Signature of Patient:
Date