ADULT MEDICAL HISTORY FORM
1. ABOUT YOU:
Today's Date:
Name:
Last
First
MI
I prefer to be called:
Male
Female
Birth date:
Age
SS#:
Home Address
City
State
Zip
Single
Married
Widowed
Divorced
Separated
Hm#:
Pager/Other#:
Wk#:
Ext:
DL#:
Email:
Employer:
Employer's Address:
How long there?
Occupation:
Where&when are best times to reach you?
Whom may we Thank for referring you?
Other family members seen by us?
General Dentist:
Last Visit Date:
Any Treatment Rendered?
2. SPOUSE'S INFORMATION
His/Her Name:
Employer:
Wk#:
Ext.
SS#:
Birth date:
Age
Person Resonsible for Account:
Wk#:
Ext.
Hm#:
Billing Address:
Relation:
SS#:
Employer:
3. ORTHODONTIC INSURANCE
Orthodontic Coverage?
Yes
No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone#:
Group# (Plan, local, or Policy #):
Insurance's Name:
Relationship to Patient:
Insured's Birthdate:
Insured's SS#:
Insured's Employer:
In the event of an emergency, is there someone who lives near you that we should contact?
His/Her Name:
Relation:
Wk#:
Hm#:
4. MEDICAL HISTORY
Do you have a personal physician?
Yes
No
Physician's Name:
Phone #:
Your Currnet physical health is:
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Please Explain:
Are you taking any prescription/over the counter drugs?
Yes
No
Please list each one:
For women:
Are you taking birth control pills?
Yes
No
Are you pregnant?
Yes
No
Week#:
Are you nursing?
Yes
No
4. MEDICAL HISTORY
continued
5. DENTAL HISTORY
Have you ever had any of the following diseases or medical problems?
What are the main concerns that you would like orthodontics to accomplish?
Y
N
Anemia/Radiation Treatment
Y
N
Artificial Bones/Joints
Y
N
Artificial Valves
Y
N
Asthma Arthritis
Y
N
Blood Transfusion
Y
N
Cancer/Chemotherapy
Y
N
Congenital Heart Defect
Y
N
Diabetes/Tuberculosis
Y
N
Difficulty Breathing
Y
N
Drug/Alcohol Abuse
Y
N
Emphysema/Glaucoma
Y
N
Epilepsy/Seizure/Fainting Spells
Y
N
Fever Blisters/Herpes
Y
N
Heart Attach/Stroke
Y
N
Heart Murmur
Please list any serious medical
condition(s) that you have ever had:
Y
N
Heart Surgery/Pacemaker
Y
N
Hemophilia/Abnormal Bleeding
Y
N
Hepatitis
Y
N
High/Low Blood Pressure
Y
N
HIV +/AIDS
Y
N
Hospitalized for Any Reason
Y
N
Kidney Problems
Y
N
Mitral Valve Prolapse
Y
N
Psychiatric Problems
Y
N
Rheumatic/Scarlet Fever
Y
N
Severe/Frequent Headaches
Y
N
Shingles
Y
N
Sinus Problems
Y
N
Ulcers/Colitis
Y
N
Veneral Disease
Are you allergic to any of the following?
Y
N
Aspirin
Y
N
Codeine
Y
N
Tetracycline
Y
N
Dental Anesthetics
Y
N
Any Metal/Plastic
Y
N
Erythromycin
Y
N
Penicillin
Y
N
Latex
Y
N
Other
Have you ever been evaluated for orthodontic treatment?
Yes
No
Have you ever had a serious/difficult problem associated with any previous dental work?
Yes
No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ / TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you like your smile?
Yes
No
Do your gums bleed?
Yes
No
Have you ever had an injury to your:
Mouth
Teeth
Chin
Do you have any speech problems?
Do you generally breathe through your mouth?
Y
N
Awake?
Y
N
Asleep?
Do you have any missing or extra permanent teeth?
Yes
No
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
Date:
Signature
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If this office accepts insurance, I understand that I am responsible for payment of services renderedand also responsible for paying any co-payment and deductibles that my insurance does not cover. I herby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Date
Signature
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