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Medical Dental History Form for Adult Patients
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Medical Dental History Form for Adult Patients
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
CĂ´te d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
CĂ´te d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
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
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