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49 Colborne St Lower Level Toronto, ON M5E 1C6
+1-888-784-7878
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Medical Dental History Form for Adult Patients
PATIENT
Date
Name
First
Last
I prefer to be called
Birth date
Sex
Male
Female
Social Insurance Number
Marital Status
Single
Married
Separated
Divorced
Widowed
Home address
City, State, Zip code
Home Phone
Cell Phone
Work Phone
Email
Occupation
Employer
CLOSEST RELATIVE
Spouse or closest relative’s name(s)
Relationship to patient
Address (if different than patient address)
Home Phone
Cell Phone
Work Phone
DENTIST
Patient’s Dentist
Address, City, State
Last seen
Reason
Next Appointment
Other dentists/dental specialists now being seen:
City, State
Reason
PHYSICIAN
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
GENERAL INFORMATION
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
City, State, Zip
Home Phone
Cell Phone
Work Phone
Social Security Number
Employer
Who will be responsible for bringing the patient to orthodontic appointments?
DENTAL INSURANCE
Primary policy holder’s full name
Birth Date
Social Security Number
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group Number
ID Number
Does this policy have orthodontic benefits?
Yes
No
Don't know
Seondary policy holder’s full name
Birth Date
Social Security Number
Relationship to patient
Address and phone (if not listed above)
Employer
Address
Insurance company
Group Number
ID Number
Does this policy have orthodontic benefits?
Yes
No
Don't know
MEDICAL INSURANCE
Policy holder’s full name
Insurance company
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
Now or in the past, have you had Birth defects or hereditary problems?
Yes
No
Don't know
Bone fractures, or major injuries?
Yes
No
Don't know
Any injuries to face, head, neck?
Yes
No
Don't know
Arthritis or joint problems?
Yes
No
Don't know
Endocrine or thyroid problems?
Yes
No
Don't know
Diabetes or low sugar?
Yes
No
Don't know
Kidney problems?
Yes
No
Don't know
Cancer, tumor, radiation treatment or chemotherapy?
Yes
No
Don't know
Stomach ulcer, hyperacidity, acid reflux?
Yes
No
Don't know
Immune system problems?
Yes
No
Don't know
History of osteoporosis?
Yes
No
Don't know
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
Yes
No
Don't know
AIDS or HIV positive?
Yes
No
Don't know
Hepatitis, jaundice or other liver problem?
Yes
No
Don't know
Polio, mononucleosis, tuberculosis, pneumonia?
Yes
No
Don't know
Seizures, fainting spells, neurologic problem?
Yes
No
Don't know
Mental health disturbance or depression?
Yes
No
Don't know
Vision, hearing, or speech problems?
Yes
No
Don't know
History of eating disorder (anorexia, bulimia)?
Yes
No
Don't know
High or low blood pressure?
Yes
No
Don't know
Excessive bleeding or bruising, anemia?
Yes
No
Don't know
Chest pain, shortness of breath, tire easily, swollen ankles?
Yes
No
Don't know
Heart defects, heart murmur, rheumatic heart disease?
Yes
No
Don't know
Angina, arteriosclerosis, stroke or heart attack?
Yes
No
Don't know
Skin disorder (other than common acne)?
Yes
No
Don't know
Do you eat a well-balanced diet?
Yes
No
Don't know
Frequent headaches or migraines?
Yes
No
Don't know
Frequent ear infections, colds, throat infections?
Yes
No
Don't know
Asthma, sinus problems, hayfever?
Yes
No
Don't know
Tonsil r adenoid condition?
Yes
No
Don't know
Do you frequently breathe through your mouth?
Yes
No
Don't know
DENTAL HISTORY
Now or in the past, have you had Permanent or extra (supernumerary) teeth removed?
Yes
No
Don't know
Supernumerary (extra) or congenitally missing teeth?
Yes
No
Don't know
Chipped or injured primary or permanent teeth?
Yes
No
Don't know
Any sensitive or sore teeth?
Yes
No
Don't know
Bleeding gums, bad taste or mouth odor?
Yes
No
Don't know
Jaw fractures, cysts, infections?
Yes
No
Don't know
Any teeth treated with root canals or pulpotomies?
Yes
No
Don't know
"Gum boils,” frequent canker sores or cold sores?
Yes
No
Don't know
History of speech problems or speech therapy?
Yes
No
Don't know
Difficulty breathing through nose?
Yes
No
Don't know
Food impaction between the teeth?
Yes
No
Don't know
Mouth breathing habit or snoring at night?
Yes
No
Don't know
History of speech problems?
Yes
No
Don't know
Frequent oral habits (sucking finger, chewing pen, etc.)?
Yes
No
Don't know
Teeth causing irritation to lip, cheek or gums?
Yes
No
Don't know
Abnormal swallowing (tongue thrust)?
Yes
No
Don't know
Tooth grinding or clenching?
Yes
No
Don't know
Clicking, locking in jaw joints?
Yes
No
Don't know
Soreness in jaw muscles or face muscles?
Yes
No
Don't know
Ringing in ears, difficulty in chewing or opening jaw?
Yes
No
Don't know
Have you ever been treated for “TMJ” or “TMD” problems?
Yes
No
Don't know
Any broken or missing fillings?
Yes
No
Don't know
Any serious trouble associate with previous dental treatment?
Yes
No
Don't know
Have you ever been diagnosed with gum disease or pyorrhea?
Yes
No
Don't know
Have you ever had an orthodontic consultation or treatment before now?
Yes
No
Don't know
Have you had allergies or reactions to any of the following:
Local anesthetics (novocaine, lidocaine, xylocaine)
Yes
No
Don't know
Latex (gloves, balloons)
Yes
No
Don't know
Aspirin
Yes
No
Don't know
Ibuprofen (Motrin, Advil)
Yes
No
Don't know
Penicillin
Yes
No
Don't know
Other antibiotics
Yes
No
Don't know
Metals (jewelry, clothing snaps)
Yes
No
Don't know
Acrylics
Yes
No
Don't know
Plant pollens
Yes
No
Don't know
Animals
Yes
No
Don't know
Foods
Yes
No
Don't know
Other substances
Yes
No
Don't know
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Medication
Taken for
Have you ever taken any medications to strengthen your bones? Please describe.
Do you take antibiotic pre-medication before any dental procedures?
Yes
No
Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
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.
Bleeding disorders
Diabetes
Arthritis
Severe allergies
Unusual dental problems
Jaw size imbalance
Other family medical conditions?
RELEASE AND WAIVER
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
Signature
Date
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.
Signature
Date
MEDICAL HISTORY UPDATES OR CHANGES
Changes
Patient Signature
Date
Dental Staff Signature
Date
Changes
Patient Signature
Date
Dental Staff Signature
Date
Changes
Patient Signature
Date
Dental Staff Signature
Date
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