Adult Health History Form
First Name:
Middle Initial:
Last Name:
Nickname:
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Email:
Work Phone:
Gender:
Male
Female
Other
Birthdate:
Social Security #:
Family Dentist:
Last Dental Visit:
Whom may we thank for referring you to our office?
Have you or any other family members been treated by our office? If so, who?
Reason for seeking orthodontic consultation?
Have you ever been seen by another orthodontist? If so, by whom and when?
Dental Insurance Information
Policy Holder's Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's SSN:
Policy Holder's DOB:
Do you have dual dental coverage?
Yes
No
(If yes, complete information below)
Policy Holder's Employer:
Employer Phone:
Insurance Company Name:
Insurance Phone:
Group Number:
Policy Number:
Member ID:
Policy Holder's Name:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
Policy Holder's SSN:
Policy Holder's DOB:
Emergency Contact Information
Name:
Address:
City:
State:
Zip:
Phone:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Self
Spouse
Stepfather
Stepmother
Other
OK to release medical information?
Yes
No
Medical History
Any Personal History of:
AIDS/HIV +?
Yes
No
Allergy to Latex?
Yes
No
Allergy to Nickel?
Yes
No
Anemia or blood disorder?
Yes
No
Arthritis, Rheumatism?
Yes
No
Artificial Bones/Joints/Valves?
Yes
No
Asthma, Hay Fever?
Yes
No
Bleeding Problems?
Yes
No
Diabetes?
Yes
No
Epilepsy or Convulsions?
Yes
No
Fainting Spells, Seizures?
Yes
No
Heart murmur?
Yes
No
Heart Trouble?
Yes
No
Hepatitis?
Yes
No
High or Low Blood Pressure?
Yes
No
Kidney or Liver Involvement?
Yes
No
Psychiatric Problems?
Yes
No
Rheumatic Fever?
Yes
No
Tuberculosis or lung disease?
Yes
No
Venereal Disease?
Yes
No
Women Only: Are you pregnant now?
Yes
No
N/A
History of hospitalization? If so, please explain.
Yes
No
Physician Name:
Please list any prescription/over-the-counter medications that you are taking:
Allergies, sensitivities or reactions to any medications?
Have you ever had to take antibiotics before dental treatment?
Yes
No
Have you ever taken bisphosphonates, such as Fosamax?
Yes
No
Do you have any disease, condition, or problem not listed above?
Dental History
Oral Habits History:
Clenching/Grinding Teeth?
Yes
No
Finger/Thumb Sucking?
Yes
No
Lip/Tongue Biting?
Yes
No
Mouth breathing?
Yes
No
Nail Biting?
Yes
No
Smoke or Chew Tobacco?
Yes
No
Any prior accidents to the mouth or teeth? If so, please explain.
Yes
No
Have tonsils and adenoids been removed? If so, please explain.
Yes
No
Do you now have, or ever had, any TMJ/jaw joint problems, such as popping, clicking, locking or pain? If so, please explain.
Yes
No
I have read and understand the above questions and affirm this information to be accurate. 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. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
Signature:
*By typing my name above I am electronically signing this form.