Adult Health History Form

Fields marked with an * are required


Patient Information





















Marital Status:

SingleMarriedDivorced












Insurance Information






Is policy connected with your union?

YesNo



General Information








Currently under dental treatment?

YesNo





Currently under physician treatment?

YesNo


Any History of:

Thumb or finger sucking?

YesNo


Grinding of teeth?

YesNo


Frequent headaches or jaw pain?

YesNo

Difficulty eating any foods?

YesNo

Speech difficulty or speech therapy?

YesNo




Medical History

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you

Are you in general good health at this time?

YesNo

Are you under any medical treatment now?

YesNo

Are you taking any drugs or medications?

YesNo

Have you ever had any adverse response to any drugs, including penicillin?

YesNo

Are you allergic to any known materials resulting in hives, asthma, eczema, etc.?

YesNo

Are you allergic to latex?

YesNo

Have you ever had any major operations including hip/joint replacement?

YesNo


Have any wounds healed slowly or presented other complications?

YesNo

Have you ever had any radiation therapy or chemotherapy?

YesNo

Have you ever had a serious accident involving head injuries?

YesNo

Have you had a history of any of the following?

AsthmaHeart murmurTumor or growthTonsillitisAids or HIV positiveFaintingDiabetesMigraine headachesCardiovascular diseaseHerpesRespiratory problemsBone disorderExcessive bleedingEpilepsyArthritis or painful jointsDrug abuseCancerSinus problemsBlood diseaseEmotional problemsConvulsionsInfectious diseaseAlcoholismSexually transmitted diseaseHay feverRheumatic feverDizzinessImmune system problemsHepatitis or liver diseaseHearing disorderOther


Do you snore?

YesNo

Do you have unexplained awakenings from sleep?

YesNo

Do you, or have you been told that you stop breathing for short periods during sleep?

YesNo

Do you get excessively tired during the day and/or fall asleep when you should be awake?

YesNo

Are you on a diet at this time?

YesNo

Do you have a history of fainting?

YesNo

Are you pregnant?

YesNo

Have you ever smoked or used Tobacco products?

YesNo


Dental History

The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.



Do your gums bleed?

YesNo

Have you ever had gum disease, or periodontal treatment?

YesNo

Do you frequently get sore spots in your mouth?

YesNo

Do you have any dental complaints at the present time?

YesNo

Do you experience frequent headaches?

YesNo

Do you have a history of back or neck injuries? Whiplash?

YesNo

Do you have any clicking or popping of your jaw? (TMJ)

YesNo

Do you have pain in or around your ears?

YesNo

Does any part of your mouth hurt when clenched?

YesNo

Do you habitually clench or grind your teeth during the night or day?

YesNo

Do you chew on only one side of your mouth?

YesNo


Are any parts of your mouth sore to pressure or irritants (cold, sweets, etc)?

YesNo


Have you ever taken any appetite suppressants (Fen-Phen, Dexfenfluramine, Fenfluramine or other)?

YesNo

Have you ever taken medication for treatment of Osteoporosis?

YesNo


Patient Emergency Info

In case of emergency, contact:




Purpose of consent (HIPAA)

By signing this form, you will consent to our use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations. Where appropriate, a credit report may be obtained.