Health-History-Adult-Form

Last Name:

First Name:

MI:

Preferred Name:

Title:

Birth Date:

Gender:

Male Female

SSN:

Marital Status:

Single

Married

Divorced

Widowed

Address: Street, City, State, Zip Code

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

Occupation:

Employer:

Dentist Name:

Dentist Address: Street, City, State, Zip Code

Dentist Phone Number:

Dentist Email:

Family in treatment with us:

How did you hear about us:

ADDITIONAL CONTACT INFORMATION

Financially Responsible Party (if not patient)

Full Name:

Relation:

Spouse Parent/Guardian

Other:

Address (if different): Street, City, State, Zip Code

Home Phone Number (if different):

Mobile Phone Number:

Work Phone Number:

Email Address:

Full Name:

Relation:

Spouse Parent/Guardian

Other:

Address: Street, City, State, Zip Code

Home Phone Number:

Mobile Phone Number:

Work Phone Number:

DENTAL INSURANCE INFORMATION

Primary Insurance

Insurance Company:

Employer:

Policy Holder Full Name:

Policy Holder SSN:

Policy Holder DOB:

Please attach photos of the front and back of your insurance card:

Front:

Back:

Secondary Insurance (if applicable)

Insurance Company:

Employer:

Policy Holder Full Name:

Policy Holder SSN:

Policy Holder DOB:

Please attach photos of the front and back of your insurance card:

Front:

Back:

Have you ever been diagnosed with the following?

anemia/bleeding disorder

Yes No

anxiety/mental health disorder

Yes No

arthritis/joint disorder

Yes No

asthma/sinus disorder

Yes No

birth defects/hereditary disorder

Yes No

cancer/tumor

Yes No

chemotherapy/radiation treatment

Yes No

chest pain/stroke/heart attack

Yes No

diabetes/low blood sugar

Yes No

eating disorder

Yes No

endocrine/thyroid disorder

Yes No

frequent ear/throat infection

Yes No

frequent migraine/headache

Yes No

GI disorder/acid reflux

Yes No

heart defect/murmur/disease

Yes No

HIV/AIDS

Yes No

immune system disorder

Yes No

kidney disorder

Yes No

osteoporosis

Yes No

polio/pneumonia/TB

Yes No

seizure/fainting/neurologic disorder

Yes No

skin disorder

Yes No

STDs

Yes No

vision/hearing/speech disorder

Yes No

Please describe any conditions not listed above:

Have you ever smoked, vaped, or used chewing tobacco?

Yes No

Have you ever used illicit drugs?

Yes No

Are you allergic to latex?

Yes No

Are you currently under the care of a medical professional?

Yes No

Have you ever taken bisphosphonate for osteoporosis?

Yes No

Please list all medications (including non-prescription and supplements):

Please list all allergies and sensitivities:

Are you pregnant?

Yes No

If yes, when are you due:

Are you nursing?

Yes No

Are you on birth control?

Yes No

Do you have a history of the following?

pending dental work

Yes No

injuries to the face/neck/mouth

Yes No

gingivitis/periodontitis

Yes No

nail/cheek/lip biting

Yes No

clenching/grinding

Yes No

clicking/popping/locking of jaw

Yes No

frequent headache/migraine

Yes No

soreness in jaw or face muscles

Yes No

Airway Disorders

removal of tonsils/adenoids

Yes No

mouth breathing

Yes No

snoring/sleep disturbances

Yes No

tiredness/irritation/sleepiness

Yes No

Please describe any conditions not listed above:

Date of last dental exam:

Have you ever required antibiotics prior to dental treatment?

Yes No

Have you ever had orthodontic treatment?

Yes No

If yes, please describe:

Reason for seeking orthodontic treatment:

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.

Patient Signature:

Date:

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

Patient Signature:

Date:

PATIENT INFORMATION

ADDITIONAL CONTACT INFORMATION

Financially Responsible Party (if not patient)

Emergency Contact

DENTAL INSURANCE INFORMATION

Primary Insurance

Secondary Insurance (if applicable)

Medical History

(female only)

DENTAL HISTORY

RELEASE AND WAIVER