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Medical Dental History Form for Adult Patients

Date*
Patient's Date of Birth*
Sex*
Marital Status

CLOSEST RELATIVE

Address (if different than patient address)

Dentist

Dentist Address

General Information

Have you had previous orthodontist treatment?*
Have any other family members been treated in this office?*
Do you think any of your work or leisure activities affect you teeth or jaws?*

Financial Responsibility

Address (if different than page 1)

Dental Insurance

Do you have Dental Insurance?*
Address (if not listed above)
Does this policy have orthodontic benefits?*
Do you have Secondary Insurance?*
Street Address (if not listed above)
Does your policy have orthodontic benefits?*

Medical Insurance

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. Now or in the past, have you had any of the following (CHECK ALL THAT APPLY)

Do you eat a well-balanced diet?*
Do you frequently breathe through your mouth?*
Have you had allergies or reactions to any of the following?

Dental History

Now or in the past, have you had:*
Has you ever been diagnosed with gum disease or pyorrhea?*

Patient Health Information

Are there any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take?*
Have you ever taken any medications to strengthen your bones? *
Do you take antibiotic pre-medication before any dental procedures?*
Do you have a substance abuse problem?*
Do you chew or smoke tobacco?*
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 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.*
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