Dental Referral Form

Date*

Name*

First Last

I prefer to be called*

Social Insurance Number*

Birth Date*

Sex*

Marital Status*

Home Address*

City, State, Zip code*

Home Phone

Cellphone

Work Phone

Email

Occupation*

Employer*

Close Relative

Spouse or closest relative's name(s)*

Relationship*

Address (if different from patient address)

Home Phone

Cellphone

Work Phone

Dentist

Patient's Dentist

Address, City, State

Last Seen

Reason

Next Appointment

Other dentists/dental specialist now being seen

Reason

City, State

Physician

Patient's Physician

Address, City, State

Last seen

Reason

Next Appointment

Most recent physical exam

Other physicians/health care providers being seen now

Name

Address, City, State

Reason

Name

Address, 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 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 RESPONSIBILITIES

Who is financially responsible for this account?*

Address*

City, State, Zip code*

Home Phone

Cellphone

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 (if not listed above)

Phone (if not listed above)

Employer

Address

Insurance company

Group Number

ID Number

Does this policy have orthodontic benefits?

Yes
No
I don't know

Secondary policy holder's full name

Birth Date

Social Security Number

Relationship to patient*

Address (if not listed above)

Phone (if not listed above)

Employer

Address

Insurance company

Group Number

ID Number

Does this policy have orthodontic benefits?

Yes
No
I don't know

MEDICAL INSURANCE

Policy holder's full name

Insurance company

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 mark yes, no or don't know/understand(dk/u).

MEDICAL HISTORY

Now or in the past, have you had Birth defects of 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 chemotheraphy?*

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

Seizure, fainting spells, neurologic problem?*

Yes
No
Don't know

Mental health disturbance or depression?*

Yes
No
Don't know

Vision, hearing, or speech problem?*

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 breath 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, ballons)*

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?

Yes
No

Do you chew or smoke tobacco?

Yes
No

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

Changes

Patient Signature

Date

Changes

Patient Signature

Date

Captcha

Medical History Form (Adult)

Close Relative

Dentist

Physician

Other physicians/health care providers being seen now

GENERAL INFORMATION

FINANCIAL RESPONSIBILITIES

DENTAL INSURANCE

MEDICAL INSURANCE

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 mark yes, no or don't know/understand(dk/u).

MEDICAL HISTORY

DENTAL HISTORY

Have you had allergies or reactions to any of the following:

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

FAMILY MEDICAL HISTORY

Have your 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 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 medical or dental health.

MEDICAL HISTORY UPDATES OR CHANGES