Health-History-Adult-Form

ADULT HEALTH HISTORY

The better we communicate, the better we can care for you. To help us meet all of your orthodontic needs, please fill out this form completely.

About You

Title:

Name:

I prefer to be called:

Male Female

Birth date:

Age:

Identify As:

Preferred Pronouns:

Email Address:

Home Address:

City, State, Zip:

Cell #:

Home #:

Work #:

Extension:

Best times to reach you?

Employer:

How long there?

Occupation:

Single

Married

Divorced

Widowed

Separated

If married, Name of Spouse:

Referred by:

Other family members seen by us:

General Dentist:

Last Visit Date:

How did you find our office:

Google

Nextdoor

Dentist

Family

Other

Billing Party

Name:

Male Female Prefer Not to Say

Birth date:

Age:

Billing Address:

E-mail Address:

Driver’s License #:

SSN:

Cell #:

Home #:

Work #:

Extension:

Employer:

How long there?

Occupation:

Orthodontic Insurance Information

Primary Dental Insurance:

Subscriber's Name:

DOB:

SSN:

Group #

I.D. #

Insurance Phone Number:

Patient's relationship to Subscriber:

Subscriber's Employer:

Secondary Dental Insurance:

Subscriber's Name:

DOB:

SSN:

Group #

I.D. #

Insurance Phone Number:

Patient's relationship to Subscriber:

Subscriber's Employer:

Medical History

Do you have a personal physician?

Yes No

Physician’s Name:

Phone #:

Date of Last Visit:

Are you currently under the care of a physician?

Yes No

Please explain:

Emergency Contact Name:

Relationship:

Cell #:

Home #:

Work #:

Extension:

Your current physical health is:

Good

Fair

Poor

Do you smoke or use tobacco in any form?

Yes No

If yes, how much per day?

How many years?

Are you taking any prescription, over-the-counter, or herbal supplemental drugs?

Yes No

If yes, please list:

Are you currently taking any bisphosphonates?

Yes No

If yes, please list:

FOR WOMEN: Are you using a prescribed method of birth control?

Yes No

Are you pregnant?

Yes No

If yes, week #:

Are you nursing?

Yes No

Have you ever had any of the following diseases or medical problems?

Abnormal Bleeding

Yes No

ADHD

Yes No

Alcohol/Drug Abuse

Yes No

Anemia

Yes No

Arthritis

Yes No

Artificial Bone(s)

Yes No

Artificial Joint(s)

Yes No

Artificial Valve(s)

Yes No

Asthma

Yes No

Autism Spectrum

Yes No

Blood Transfusion

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Colitis

Yes No

Congenital Heart Defect

Yes No

Diabetes

Yes No

Difficulty breathing

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting Spells

Yes No

Fever Blisters

Yes No

Frequent Headaches

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack

Yes No

Heart murmur

Yes No

Heart Surgery

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

HIV+/AIDS

Yes No

Kidney Problems

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lupus

Yes No

Mitral Valve Prolapse

Yes No

Prolapse

Yes No

Pacemaker

Yes No

Psychiatric Problems

Yes No

Radiation Treatment

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Seizures

Yes No

Sensory Processing Disorder

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus problems

Yes No

Sleep apnea

Yes No

Snoring

Yes No

Stroke

Yes No

Thyroid Problems

Yes No

Tuberculosis (TB)

Yes No

Ulcer

Yes No

Hospitalized for Any Reason?

Yes No

If yes, please explain:

Please list any other medical conditions that you have had:

Is pre-treatment medication necessary such as antibiotic prophylaxis?

Yes No

Are you allergic to any of the following?

Aspirin

Yes No

Metal

Yes No

Codeine

Yes No

Penicillin

Yes No

Dental Anesthetics

Yes No

Plastic

Yes No

Erythromycin

Yes No

Tetracycline

Yes No

Latex

Yes No

Please list any other drugs/materials that you are allergic to:

Dental History

What are the main concerns that you would like orthodontics to accomplish?

Have you ever had a serious or difficult problem associated with any previous dental work?

Yes No

Do you have or have you ever experienced pain or discomfort in your jaw joint (TMJ/TMD)?

Yes No

Explain:

Your current dental health is:

Good

Fair

Poor

Do you like your smile?

Yes No

Do your gums ever bleed?

Yes No

Have you ever had an injury to your:

Mouth Teeth Chin

Do you have any speech problems?

Yes No

Have you ever experienced any of the following habits? Mark all that apply.

Clenching

Grinding

Excessive mouth breathing

Nail biting

Thumb and/for Finger Sucking

Lip Sucking and/or biting

None of the above

Dental History? Mark all that apply.

Previously evaluated for orthodontic treatment

Currently in orthodontic treatment

Had orthodontic treatment in the past

Serious or difficult problem(s) with previous dental work

Pain or discomfort in jaw joint (possibly due to TMD)

Speech problems

Smoking and/or tobacoo use

Bleeding gums

Congenitally missing teeth

Extra permanent teeth

Wisdom teeth have been extracted

Tonsils removed

Adenoids removed

Brush teeth daily

Floss teeth daily

None of the above

Other

Treatment preference (if any):

Clear aligners

Braces

No preference

Do you require any fillings, crowns, or other restorative dental work before starting treatment?

Yes No

If yes, explain:

Authorizations

Date:

I affirm that the information I have given is correct to the best of my knowledge. It 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 orthodontia staff to perform the necessary orthodontia services with my informed consent that I may need during diagnosis and treatment.

Signature

I certify that I am covered by

Insurance Co. and I assign directly to Sloss & Carpenter Orthodontics all insurance benefits, otherwise payable to me. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electric.

Signature

PAYMENT IS DUE AT THE TIME OF SERVICE

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING PROVIDERS/ FACILITIES IN THE FUTURE.

Please print your name:

Please sign your name

Guardian name (please print):

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes stepparents, grandparents and any care takers who can have access to this patient’s records):

Name:

Relationship:

Name:

Relationship:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.