Adult Medical History Form Patient Last Name First Name MI Title: Mr. Dr. Mrs. Ms. Other Preferred Name Date of Birth Social Security # Marital Status: Single Married Separated Divorced Widowed Sex: Male Female Home Address City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Email Address Occupation Employer Instagram @ Closest Relative Closest Relative Name Title: Mr. Dr. Mrs. Ms. Other Home Address (if different) City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Dentist Patient's Dentist Address City State (e.g. NJ) Zip Code Last seen (mm/dd/yyyy) Reason Next Appointment (mm/dd/yyyy) Other dentists being seen: Name City State (e.g. NJ) Reason Physician Patient's Physician Address City State (e.g. NJ) Zip Code Last seen (mm/dd/yyyy) Reason Next Appointment Most Recent Physical Exam Other physicians being seen: Name City State (e.g. NJ) Reason Name City State (e.g. NJ) Reason General Information What concerns you about your teeth? Who suggested that you might need orthodontic treatment? Why did you select our office? Describe any previous orthodontic treatment or consultations: Do you think any of your work or leisure activities affect your teeth or jaws? Please explain: Financial Responsibility Who is financially responsible for this account? Address (if different) City State (e.g. NJ) Zip Code Home Phone Cell Phone Work Phone Email Address Social Security # Employer Who will be bringing the patient to orthodontic appointments? Dental Insurance Primary policy holder's full name Date of Birth Social Security # Email Address Home Phone Cell Phone Work Phone Address (if different) City State (e.g. NJ) Zip Code Employer Employer's Address City State (e.g. NJ) Zip Code Insurance company Group # ID # Does this policy have orthodontic benefits? Yes No Unsure Secondary policy holder's full name Date of Birth Social Security # Email Address Home Phone Cell Phone Work Phone Address (if different) City State (e.g. NJ) Zip Code Employer Employer's Address City State (e.g. NJ) Zip Code Insurance company Group # ID # Does this policy have orthodontic benefits? Yes No Unsure Medical History 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 unsure. Now or in the past, have you had: Yes No Unsure Birth defects or hereditary problems? Please explain: Yes No Unsure Bone fractures, or major injuries? Please explain: Yes No Unsure Any injuries to face, head, neck? Please explain: Yes No Unsure Arthritis or joint problems? Please explain: Yes No Unsure Cancer, tumor, radiation treatment or chemotherapy? Please explain: Yes No Unsure Endocrine or thyroid problems? Please explain: Yes No Unsure Diabetes or low sugar? Please explain: Yes No Unsure Kidney problems? Please explain: Yes No Unsure Immune system problems? Please explain: Yes No Unsure History of osteoporosis? Please explain: Yes No Unsure Gonorrhea, syphilis, herpes, sexually transmitted diseases? Please explain: Yes No Unsure AIDS or HIV positive? Please explain: Yes No Unsure Hepatitis, jaundice or other liver problems? Please explain: Yes No Unsure Polio, mononucleosis, tuberculosis, pneumonia? Please explain: Yes No Unsure Stomach ulcers, hyperacidity, acid reflux? Please explain: Yes No Unsure Seizures, fainting spells, neurologic problem? Please explain: Yes No Unsure Mental health disturbance or depression? Please explain: Yes No Unsure History of eating disorder (anorexia, bulimia)? Please explain: Yes No Unsure Frequent headaches or migraines? Please explain: Yes No Unsure High or low blood pressure? Please explain: Yes No Unsure Excessive bleeding or bruising tendency, anemia? Please explain: Yes No Unsure Chest pain, shortness of breath, tire easily, swollen ankles? Please explain: Yes No Unsure Heart defects, heart murmur, rheumatic heart disease? Please explain: Yes No Unsure Angina, arteriosclerosis, stroke or heart attack? Please explain: Yes No Unsure Skin disorder (other than common acne)? Please explain: Yes No Unsure Do you eat a well-balanced diet? Please explain: Yes No Unsure Vision, hearing, or speech problems? Please explain: Yes No Unsure Frequent ear infections, colds, throat problems? Please explain: Yes No Unsure Asthma, sinus problems, hayfever? Please explain: Yes No Unsure Tonsil or adenoid problems? Please explain: Yes No Unsure Do you frequently breathe through your mouth? Please explain: Have you had allergies or reactions to any of the following? Yes No Unsure Local anesthetics (novocaine, lidocaine, xylocaine) Please explain: Yes No Unsure Latex (gloves, balloons) Please explain: Yes No Unsure Aspirin Please explain: Yes No Unsure Ibuprofen (Motrin, Advil) Please explain: Yes No Unsure Penicillin Please explain: Yes No Unsure Other antibiotics Please explain: Yes No Unsure Metals (jewelry, clothing snaps) Please explain: Yes No Unsure Acrylics Please explain: Yes No Unsure Plant Pollens Please explain: Yes No Unsure Animals Please explain: Yes No Unsure Foods Please explain: Yes No Unsure Other substances Please explain: Dental History Now or in the past, have you had: Yes No Unsure Permanent or extra (supernumerary) teeth removed? Please explain: Yes No Unsure Supernumerary (extra) or congenitally missing teeth? Please explain: Yes No Unsure Chipped or injured primary or permanent teeth? Please explain: Yes No Unsure Any sensitive or sore teeth? Please explain: Yes No Unsure Any lost or broken fillings? Please explain: Yes No Unsure Jaw fractures, cysts, infections? Please explain: Yes No Unsure Any teeth treated with root canals or pulpotomies? Please explain: Yes No Unsure “Gum boils,” frequent canker sores or cold sores? Please explain: Yes No Unsure Bleeding gums, bad taste or mouth odor? Please explain: Yes No Unsure Food impaction between teeth? Please explain: Yes No Unsure History of speech problems or speech therapy? Please explain: Yes No Unsure Difficulty breathing through nose? Please explain: Yes No Unsure Mouth breathing habit or snoring at night? Please explain: Yes No Unsure Frequent oral habits (sucking finger, chewing pen, etc.)? Please explain: Yes No Unsure Teeth causing irritation to lip, cheek or gums? Please explain: Yes No Unsure Tooth grinding or clenching? Please explain: Yes No Unsure Clicking, locking in jaw joints? Please explain: Yes No Unsure Soreness in jaw muscles or face muscles? Please explain: Yes No Unsure Ringing in ears, difficulty in chewing or opening jaw? Please explain: Yes No Unsure Any teeth treated with root canals or pulpotomies? Please explain: Yes No Unsure Have you ever been treated for “TMJ” or “TMD” problems? Please explain: Yes No Unsure Any serious trouble associated with previous dental treatment? Please explain: Yes No Unsure Have you ever been diagnosed with gum disease or pyrrhea? Please explain: Yes No Unsure Have you ever had an orthodontic consultation or treatment before? Please explain: Patient Health Information List any medication, nutritional supplements, herbal medications, or non-prescription medicines (including fluoride supplements) that you take: Medication Taken for Medication Taken for Medication Taken for Yes No Do you take antibiotic premedication before any dental procedures? Yes No Do you have (or ever had) a substance abuse problem? Yes No Do you chew or smoke tobacco? Yes No Have you noticed any unusual changes in your face or jaws? Any other physical problems? Are you pregnant? Are you trying to become pregnant? 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 do you brush? (times/day) How often do you floss? (times/day) Submit with DocuSign
