Date:
PT Info & Medical History Form
PATIENT INFORMATION
PATIENT’S NAME:
NICKNAME:
HOME ADDRESS:
CITY:
ST:
ZIP:
Home Phone:
Cell Phone:
BIRTHDATE:
PATIENT’S DENTIST:
DATE OF LAST VISIT:
IF PATIENT IS A MINOR, PARENT’S OR GUARDIAN’S NAME:
IF PATIENT IS A MINOR, PARENT’S MARITAL STATUS:
SINGLE
MARRIED
WIDOWED
DIVORCED
SEPARATED
DOES THE PERSON NAMED ABOVE HAVE LEGAL CUSTODY OF CHILD?
Yes
No
IS ANOTHER MEMBER OF YOUR FAMILY A PATIENT OF DR. HORANI’S?
Yes
No
THEIR NAME:
RESPONSIBLE PARTY INFORMATION
CHECK HERE IF RESPONSIBLE PARTY IS SAME AS ABOVE:
NAME:
HOME ADDRESS:
BILLING ADDRESS (IF DIFFERENT THAN HOME):
SOCIAL SECURITY #:
BIRTH DATE:
RELATIONSHIP TO PATIENT:
EMPLOYER :
OCCUPATION:
# YEARS EMPLOYED:
SPOUSE’S NAME:
RELATIONSHIP TO PATIENT:
SOCIAL SECURITY #:
BIRTH DATE:
EMPLOYER :
OCCUPATION:
# YEARS EMPLOYED:
INSURANCE INFORMATION
INSURED’S NAME:
BIRTHDATE:
RELATIONSHIP TO PATIENT:
SOCIAL SECURITY #:
INSURANCE CO. NAME:
INSURANCE CO. PHONE #:
INSURED’S EMPLOYER:
EMERGENCY INFORMATION
NAME OF NEAREST RELATIVE NOT LIVING WITH YOU:
COMPLETE ADDRESS:
PHONE #:
HEALTH HISTORY
PHYSICIAN’S NAME:
DATE OF LAST PHYSICAL EXAMINATION:
ADDRESS:
PHONE #:
YOUR CURRENT PHYSICAL HEALTH IS
GOOD
FAIR
POOR
HAVE YOU BEEN UNDER THE CARE OF A PHYSICIAN IN THE LAST TWO YEARS?
Yes
No
IF YES, PLEASE EXPLAIN:
HAVE YOU TAKEN/ ARE YOU CURRENTLY TAKING ANY PRESCRIPTION/OVER-THE-COUNTER MEDICATIONS OR DRUGS DURING THE PAST TWO YEARS?
Yes
No
IF YES, PLEASE LIST AND GIVE DATES TAKEN:
ARE YOU AWARE OF BEING ALLERGIC TO, OR HAVE YOU EVER REACTED ADVERSELY TO ANY MEDICATION OR SUBSTANCE
Yes
No
HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING DISEASES OR MEDICAL PROBLEMS?
HEART ATTACK
Yes
No
STROKE
Yes
No
HEART SURGERY
Yes
No
HEART PACEMAKER
Yes
No
HEART MURMUR
Yes
No
CONGENITAL HEART DEFECT
Yes
No
MITRAL VALVE PROLAPSE
Yes
No
HIGH/LOW BLOOD PRESSURE
Yes
No
ANEMIA
Yes
No
HEMOPHILIA
Yes
No
BRUISE EASILY
Yes
No
HOSPITALIZED FOR ANY REASON
Yes
No
ADDICENT/FRACTURE
Yes
No
ENDOCRINE OR THYROID PROBLEMS
Yes
No
KIDNEY PROBLEMS
Yes
No
SHINGLES
Yes
No
COLD SORES/FEVER BLISTERS
Yes
No
SEVERE/FREQUENT HEADACHES
Yes
No
EPILEPSY/SEIZURES
Yes
No
FAINTING/DIZZY SPELLS
Yes
No
NERVOUSNESS
Yes
No
PSYCHIATRIC TREATMENT
Yes
No
MUMPS, PNEUMONIA
Yes
No
DIFFICULTY BREATHING
Yes
No
ADENOIDS REMOVED
Yes
No
TONSILS REMOVED
Yes
No
GLAUCOMA
Yes
No
EMPHYSEMA
Yes
No
ALLERGIES/HAY FEVER
Yes
No
ASTHMA
Yes
No
DRUG/ALCOHOL ADDICTION
Yes
No
PROBLEMS WITH THE IMMUNE SYSTEM
Yes
No
HIV/AIDS
Yes
No
HEPATITIS A (INFECTIOUS)
Yes
No
HEPATITIS B
Yes
No
DIABETES
Yes
No
CANCER/CHEMOTHERAPY
Yes
No
BIRTH DEFECTS OR HEREDITARY PROBLEMS
Yes
No
ARTHRITIS/RHEUMATISM
Yes
No
EATING DISORDER
Yes
No
VENEREAL DISEASE
Yes
No
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?
LOCAL ANESTHETICS
Yes
No
ASPIRIN
Yes
No
IBUPROFEN
Yes
No
PENICILLIN/ANTIBIOTICS
Yes
No
SULFA DRUGS
Yes
No
CODEINE/NARCOTICS
Yes
No
METALS
Yes
No
LATEX
Yes
No
ACRYLIC
Yes
No
ANIMALS
Yes
No
FOODS (SPECIFY)
Yes
No
OTHER SUBSTANCES
Yes
No
HAS PUBERTY BEGUN?
Yes
No
GIRLS: HAS MENSTRUATION BEGUN?
Yes
No
IS THE PATIENT PREGNANT?
Yes
No
HOW OFTEN DOES PATIENT BRUSH?
FLOSS?
HAVE YOU HAD ANY OF THE FOLLOWING?
PRIMARY (BABY) TEETH REMOVED THAT WERE NOT LOOSE
Yes
No
SUPERNUMERARY (EXTRA) OR CONTENITALLY MISSING TEETH
Yes
No
TEETH SENSITIVE TO HOT/COLD; TEETH THROB OR ACHE
Yes
No
JAW FRACTURES, CYSTS OR MOUTH INFECTIONS
Yes
No
“DEAD” TEETH, OR ROOT CANALS TREATED
Yes
No
BLEEDING GUMS, BAD TASTE, OR MOUTH ODOR
Yes
No
THUMB, FINGER, OR SUCKING HABIT?
Yes
No
UNTIL WHAT AGE
ABNORMAL SWALLOWING HABIT (TONGUE THRUSTING)
Yes
No
HISTORY OF SPEECH PROBLEMS
Yes
No
MOUTH BREATHING HABIT/SNORING/DIFFICULTY BREATHING
Yes
No
TOOTH GRINDING OR JAW CLENCHING
Yes
No
ANY PAIN IN JAW OR RINGING IN EARS
Yes
No
DIFFICULTY ENCOUNTERED IN CHEWING OR JAW OPENING
Yes
No
ANY TEETH IRRITATING CHEEK, LIP, TONGUE OR PALATE
Yes
No
CONCERNED ABOUT SPACED, CROOKED OR PROTRUDING TEETH
Yes
No
AWARE OF CONCERNED ABOUT UNDER OR OVER DEVELOPED JAW
Yes
No
HAVE YOU BEEN EVALUATED FOR ORTHODONTIC TREATMENT
Yes
No
ANY SERIOUS TROUBLE ASSOCIATED WITH ANY PREVIOUS DENTAL TREATMENT
Yes
No
EVER HAD A PRIOR ORTHODONTIC EXAMINATION OR TREATMENT
Yes
No
WHAT IS YOUR PRIMARY CONCERN (WHY ARE YOU HERE)?
WHO MAY WE THANK YOU REFERRING YOU/HOW DID YOU SELECT OUR OFFICE?
I HAVE READ AND UNDERSTAND THE ABOVE QUESTIONS. I WILL NOT HOLD DR. HORANI OR ANY MEMBER OF 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 INFORM THE STAFF.
RELATIONSHIP TO PATIENT:
PRINTED NAME:
SIGNED
DATE SIGNED: