Medical Dental History Form for Adult Patients

Thank you for taking the time to fill this form out completely. We are excited that you have selected us to provide orthodontic care for your family!

Confidential Patient Information

Whom may we thank for referring you to our office:
In your own words, describe main orthodontic concern:
* First Name:
MI:
* Last Name:
Age:
Prefer to be called:
* Birthdate:
* Sex:
Height:
Weight:
Hobbies:
* Address:
* City:
* State:
* Zip:
How long at this address?
* Home Phone:
Cell Phone:
Email:
Previous Address If Less Than 1 Year:
Employer:
Business Address:
Work Phone:
Driver's License Number:
SS #:

Spouse's Name:
DOB:
Employer:
Business Address:
Work Phone:
Driver's License Number:
SS #:

Insurance Information

Insured's Name:
Insured's ID #:
Insurance Company:
Group No.:
Insurance Co. Address:
Insurance Co. Phone No.:
Is policy connected with your union?
Name of Union:
Union Local #:
Do you have Dual Coverage?      (If yes, please complete the following)

Insured's Name:
Insured's ID #:
Insurance Company:
Group No.:
Insurance Co. Address:
Insurance Co. Phone No.:
Is policy connected with your union?
Name of Union:
Union Local #:

General Information

Name of any family member in treatment or previously had treatment with us:
Number of children in family
Ages
Have you had previous orthodontic treatment?
If yes, how long ago?
Name of previous orthodontist:
General Dentist Name:
Address:
Phone #:
Date of last dental check-up:
Currently undergoing treatment?

Medical History

Are you in general good health at this time?
Women: Are you pregnant or plan to become pregnant in the next year?
Are you being treated for any medical conditions? If yes, please list.
Are you taking any drugs or medications? If yes, please list.
Have you had any adverse response to any drugs, including penicillin? If yes please list.
Are you allergic to any known materials including latex resulting in hives, asthma, eczema etc?
Do you require antibiotic premedication prior to any dental procedure?
Do you have any history of major illness? If yes, please describe.
Have you ever been hospitalized? If yes, please describe.
Have you had any surgical procedures? If yes, please describe.
Now or in the past have you had: (please check all that apply)

Do you snore?
Do you have unexplained awakenings from sleep?
Do you stop breathing for short periods during sleep?
Do you get excessively tired during the day and/or fall asleep when they should be awake?
Are you on a diet at this time?
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), Actone(ridenfronate), Boniva (bandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Have you ever smoked or used tobacco products?
Do you have any medical conditions not previously mentioned? If yes, please describe.

Dental History

Any History Of:
* Thumb or finger sucking?
If yes, until what age?
* Speech difficulty or speech therapy?
* Do your gums bleed?
* Have you ever had gum disease, or periodontal treatment?
* Do you have any dental complaints at the present time? If yes, please describe.
* Have there been any injuries to the face, mouth, or teeth? If yes, please describe.
* Do you experience frequent headaches?
* Do you have a history of back or neck injuries?
* Do you have any clicking or popping of their jaw (TMJ)?
* Do you have pain in or around the ears?
* Does any part of your mouth hurt when clenched?
* Do you habitually clench or grind his/her teeth during the night or day?
* Do you chew on only one side of his/her mouth?
* Do you have difficulty eating foods?
* Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc)?
Do you have any dental conditions not previously mentioned? If yes, please describe.

Emergency Information

Name:
Phone:
Relationship to Patient:

Purpose of Consent (HIPPA) By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations.

CONSENT FOR EXAMINATION & CREDIT REPORT (WHEN REQUIRED) – PARENT/CUSTODIAL PARENT/LEGAL GUARDIAN SIGNATURE REQUIRED:

Patient Signature:
Date: