Biographical Adult Form

Health History (Adult)

Patient Name:

Date of Birth:

Sex ( Circle one ): M F

Mailing Address:

City:

Prov:

Postal Code:

Primary Phone Number:

Dentist Name / Clinic:

Date of last visit:

Have you ever had any of the following?

Clicking Jaw Joint

Locking Jaw

Teeth or Jaw injuries /Accidents

Oral habits:

Mouth Breathing

Thumb / Finger or Pacifier Sucking

Nail Biting / Chewing

Lip / Cheek Habits

Teeth Grinding / Clenching

Other:

Have you ever had any of the following?

Rheumatic Fever?

Hepatitis?

Abnormal heart conditions?

Diabetes?

Abnormal bleeding from cuts?

Allergies:

Are you taking any prescription or non-prescription medications?

Has anyone in your family had treatment done by Yorkton Orthodontics? If yes, please name

What concerns you the most about your teeth?

Primary Insurance:

Name of Insurance Holder:

DOB:

Policy / Group Number:

Certificate / ID Number:

Secondary Insurance:

Name of Insurance Holder:

DOB:

Policy / Group Number:

Certificate / ID Number:

Treaty Number:

Band Name & Phone Number: