Medical Dental History Form for Adult Patients

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Medical Dental History Form for Patients Under Age 18

Patient
Date
Name
First Last
Prefers to be called
Hobbies, Activities
Birthdate
Sex
- Male
- Female
Social Insurance Number
School
Grade
Email
Home Address
City, State, Zip Code
Home Phone
Cell Phone
PARENT/GUARDIAN
Custodial Parent(s) Name(s)
Patient Lives With (check all that apply)
- Mother
- Father
- Stepmother
- Stepfather
- Grandparents
- Other
Father's Full Name
Occupation
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
Mother's Full Name
Occupation
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Work Phone
DENTIST
Patient's Dentist
Address, City, State, ZIP
Last Seen
Reason
Next Appointment
Other Dentists Now Being Seen
City, State
Reason
GENERAL INFORMATION
What concerns you have about your child’s teeth?
What concerns your child have about his/her teeth?
How does your child feel about orthodontic treatment?
Who suggested that your child might need orthodontic treatment?
Why did you select our office?
Describe any previous orthodontic treatment or consultations.
Does your child play a musical instrument?
Brother/Sister Name and Age
Had orthodontic treatment?
If yes, where?
Brother/Sister Name and Age
Had orthodontic treatment?
If yes, where?
Brother/Sister Name and Age
Had orthodontic treatment?
If yes, where?
Brother/Sister Name and Age
Had orthodontic treatment?
If yes, where?
Have any other family members been treated in this office? Please name them.
FINANCIAL RESPONSIBILITY
Who is financially responsible for this account?
Address (if different from page 1)
City, State
Home Phone
Cell Phone
Email
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
Insurance Company
Group Number
ID Number
Does this policy have orthodontic benefits?
- Yes
- No
- Don't Know
Secondary policy holder’s full name
Birth Date
Social Security Number
Relationship to Patient
Address and phone (if not listed above)
Employer
Insurance Company
Group Number
ID Number
Does this policy have orthodontic benefits?
- Yes
- No
- Don't Know
MEDICAL INSURANCE
Policy holder’s full name (Medical Insurance)
Insurance company
PHYSICIAN
Patient’s Physician
City, State
Last seen
Reason
Next appointment
Most recent physical exam
Name of other physicians/health care providers being seen now:
City, State
Reason
Name of other physicians/health care providers being seen now:
City, State
Reason
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).
MEDICAL HISTORY
Now or in the past, has your child 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
Cancer, tumor, radiation treatment or chemotherapy?
- Yes
- No
- Don't know
Endocrine or thyroid problems?
- Yes
- No
- Don't know
Diabetes or low sugar?
- No
- Yes
- Don't know
Kidney problems?
- 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 problems?
- 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
History of eating disorder (anorexia, bulimia)?
- Yes
- No
- Don't know
Frequent headaches or migraines?
- Yes
- No
- Don't know
High or low blood pressure?
- Yes
- No
- Don't know
Excessive bleeding or bruising tendency, 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
Does your child eat a well-balanced diet?
- Yes
- No
- Don't know
Vision, hearing, or speech problems?
- 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 or adenoid condition?
- Yes
- No
- Don't know
Does your child frequently breathe through his/her mouth?
- Yes
- No
- Don't know
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
- Yes
- No
- Don't know
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
- Yes
- No
- Don't know
Has your child had allergies or reactions to Local anesthetics (novocaine, lidocaine, xylocaine)
- Yes
- No
- Don't know
Allergies to Latex (gloves, balloons)
- Yes
- No
- Don't know
Allergies to Aspirin
- Yes
- No
- Don't know
Ibuprofen (Motrin, Advil)
- Yes
- No
- Don't know
Allergies to 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
- Dont 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
DENTAL HISTORY
Now or in the past, has the patient had Erupting teeth very early or very late?
- Yes
- No
- Don't know
Primary (baby) teeth removed that were not loose?
- Yes
- No
- Don't know
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
Any lost or broken fillings?
- 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
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
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
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
Has your child 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 associated with previous dental treatment?
- Yes
- No
- Don't know
Has your child ever been diagnosed with gum disease or pyorrhea?
- Yes
- No
- Don't know
PATIENT HEALTH INFORMATION
Do you think that any of your child’s activities affect his/her face, teeth or jaws? How?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.

Medication	Taken for

Do you take antibiotic pre-medication before any dental procedures?
- Yes
- No
Does the patient currently have (or ever had) a substance abuse problem?
Does your child chew or smoke tobacco?
Have you noticed any unusual changes in your child’s face or jaws?
Any other physical problems?
FAMILY MEDICAL HISTORY
Have the 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?
How often does your child brush?
Floss?
RELEASE AND WAIVER
I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.
Parent/Guardian 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 child’s medical or dental health.
Parent/Guardian Signature
Date
MEDICAL HISTORY UPDATES
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Changes
Parent/Guardian Signature
Date
Dental Staff Signature
Date
Captcha

Medical Dental History Form for Adult Patients

Medical Dental History Form for Patients Under Age 18

Patient

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

Have the parents or siblings ever had any of the following health problems? If so, please explain.

RELEASE AND WAIVER

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

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 child’s medical or dental health.

MEDICAL HISTORY UPDATES