Falsafi Ortho | Adult Form

CONFIDENTIAL

Medical Dental History Form for Adult Patients

Patient's Last name

First name

Middle initial

Title
Mr.
Mrs.
Ms.
Miss.
Dr.

Other

I prefer to be called

Birth date

Sex: Male Female

Social Security #

Marital Status
Single
Married
Separated
Divorced
Widowed

Home address

City

State

Zip code

Cell phone

Home phone

Work phone

E-mail address(es)

Occupation

Employer

Spouse or closest relative’s name(s)

Title
Mr.
Mrs.
Ms.
Miss.
Dr.

Other

Relationship to patient

Address (if different than patient address)

Cell phone

Home phone

Work phone

Patient’s Dentist

Address,

City

State

Last seen

Reason

Next appointment

Other dentists/dental specialists now being seen:

Name

City

State

Reason

Patient’s Physician

City

State

Last seen

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now:

Name

City,

State

Reason

Name

City,

State

Reason

What concerns you about your teeth?

Who suggested that you might need orthodontic treatment?

Why did you select our office?

Have you had any previous orthodontic treatment? Please describe

Have any other family members been treated in this office? Please name them.

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (if different from page 1)

City

State

Zip

Cell phone

Home phone

E-mail address(es)

Social Security #

Employer

Who will be responsible for bringing the patient to orthodontic appointments?

Primary policy holder’s full name

Birthdate

Social Security #

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes No Don’t know

Secondary policy holder’s full name

Birthdate

Social Security #

Relationship to patient

Address and phone (if not listed above)

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes No Don’t know

Policy holder’s full name

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).

Have you had allergies or reactions to any of the following:

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Do you take antibiotic pre-medication before any dental procedures?

Yes No

Medication

Taken for

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe.

Do you or have you ever had a substance abuse problem?

Have you chewed tobacco

Yes No

smoked any substance or vaped?

Yes No

If yes, what is the frequency?

Have you noticed any changes in your face or jaws?

Any other physical problems?

How often do you brush?

How often do you floss?

Women: Are you pregnant?

Yes No

Are you trying to become pregnant?

Yes No

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Unusual dental problems

Other family medical conditions?

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.

MEDICAL HISTORY UPDATES OR CHANGES

Patient Signature

Date:

Dental Staff Signature

Date:

Patient Signature

Date:

Dental Staff Signature

Date:

Patient Signature

Date:

Dental Staff Signature

Date:

CONFIDENTIAL

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).

MEDICAL HISTORY

DENTAL HISTORY

Have you had allergies or reactions to any of the following:

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

MEDICAL HISTORY UPDATES OR CHANGES