Adult Medical Dental History

1. Patient Information

Patient's last name —

First name —

Middle initial —

Title —

Other —

I prefer to be called —

Birth Date —

Sex —

Social Security# (Optional) —

Marital Status —

Home address —

City —

State —

Zip —

Email —

Home phone —

Cell phone —

Work phone —

Occupation —

Employer —

Closest Relative

Spouse or closest relatives name(s) —

Relationship to patient —

Title —

Other —

Home phone —

Address (is equal to patient information?) —

Address —

Cell phone —

Work phone —

Dentist

Patient's Dentist —

Address —

City —

State —

Last seen —

Reason —

Next appointment —

Other dentist: Name —

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 had 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. —

2. Financial Responsibility

Who is financially responsible for this account? —

Address (is equal to patient information?) —

Address —

City —

State —

Zip —

Home phone —

Cell phone —

Email address(es) —

Social Security # —

Employer —

3. Insurance Information

Dental Insurance

Primary policy holder's full name —

Birth date —

Social Security # —

Relationship to patient —

Address (is equal to patient information?) —

Phone (is equal to patient information?) —

Address —

Phone —

Employer —

Address —

Insurance company —

Group # —

ID # —

Does this policy have orthodontic benefits? —

Secondary policy holder's full name —

Birth date —

Social Security # —

Relationship to patient —

Address (is equal to patient information?) —

Phone (is equal to patient information?) —

Address —

Phone —

Employer —

Address —

Insurance company —

Group # —

ID # —

Does this policy have orthodontic benefits? —

Medical Insurance

Policy holder's full name —

Insurance Company —

4. Medical Information

Physician

Patient's Physician —

City —

State —

Last seen —

Reason —

Next appointment —

Most recent physical exam —

Other physicians/health care providers being seen now:

Name —

City —

State —

Reason —

Name —

City —

State —

Reason —

Medical History

Now or in the past, have you had:

Birth defects or hereditary problems? —

Bone fractures or major injuries? —

Any injuries to face, head, neck? —

Arthritis or joint problems? —

Endocrine or thyroid problems? —

Diabetes or low sugar? —

Kidney problems? —

Cancer, tumor, radiation treatment or chemotherapy? —

Stomach ulcer, hyperacidity, acid reflux? —

Immune system problems? —

History of osteoporosis? —

Gonorrhea, syphilis, herpes, sexually transmitted diseases? —

AIDS or HIV positive? —

Hepatitis, jaundice, or other liver problems? —

Polio, mononucleosis, tuberculosis, pneumonia? —

Seizures, fainting spells, neurologic problems? —

Mental health disturbance or depression? —

Vision, hearing, or speech problems? —

History of eating disorder (anorexia, bulimia)? —

High or low blood pressure? —

Excessive bleeding or bruising, anemia? —

Chest pain, shortness of breath, tire easily, swollen ankles? —

Heart defects, heart murmur, rheumatic heart disease? —

Angina, arteriosclerosis, stroke or heart attack? —

Skin disorder (other than common acne)? —

Do you eat a well-balanced diet? —

Frequent headaches or migraines? —

Frequent ear infections, colds, throat infections? —

Asthma, sinus problems, hayfever? —

Tonsil or adenoid condition? —

Do you frequently breathe through your mouth? —

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

Local anesthetics (novocaine, lidocaine, xylocaine) —

Latex (gloves, balloons) —

Aspirin —

Metals (jewelry, clothing snaps) —

Penicillin —

Other antibiotics —

Ibuprofen (Motrin, Advil) —

Acrylics —

Plant pollens —

Animals —

Foods —

Other substances —

Dental History

Now or in the past, have you had:

Permanent or extra (supernumerary) teeth removed? —

Supernumerary (extra) or congenitally missing teeth? —

Chipped or injured primary or permanent teeth? —

Any sensitive or sore teeth? —

Bleeding gums, bad taste or mouth odor? —

Jaw fractures, cysts, infections? —

Any teeth treated with root canals or pulpotomies? —

“Gum boils”, frequent canker sores or cold sores? —

History of speech problems or speech therapy? —

Difficulty breathing through nose? —

Food impaction between the teeth? —

Mouth breathing habit or snoring at night? —

Frequent oral habits (sucking finger, chewing pen, etc)? —

Teeth causing irritation to lip, cheek or gums? —

Abnormal swallowing (tongue thrust)? —

Tooth grinding or clenching? —

Clicking, locking in jaw joints? —

Soreness in jaw muscles or face muscles? —

Ringing in ears, difficulty in chewing or opening jaw? —

Have you ever been treated for “TMJ” or “TMD” problems? —

Any broken or missing fillings? —

Any serious trouble associated with previous dental treatment? —

Have you ever been diagnosed with gum disease or pyorrhea? —

Have you ever had an orthodontic consultation or treatment before now? —

Patient Health Information

Medication —

Taken for —

Medication —

Taken for —

Medication —

Taken for —

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? —

Do you or have you ever had a substance abuse problem? —

Do you chew or smoke tobacco? —

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? —

Are you trying to become pregnant? —

Family Medical History

Bleeding disorders —

Diabetes —

Arthritis —

Severe allergies —

Unusual dental problems —

Jaw size imbalance —

Other family medical conditions? —

5. Release and Waiver

Signature —

6. Medical History Updates or Changes

Change 1

Changes —

Parent/Guardian Signature —

7. Adult STOP – BANG Sleep Questionnaire

Name —

Height (inches) —

Weight (pounds) —

BMI —

Age —

Sex —

STOP

Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? —

Do you often feel TIRED, fatigued, or sleepy during the daytime? —

Has anyone OBSERVED you stop breathing during your sleep? —

Do you have or are you being treated for high blood PRESSURE? —

BANG

BMI more than 24? —

AGE over 50 years old? —

NECK circumference greater than 16 inches (40 cm)? —

GENDER: Male? —

8. Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I, (write name and surname) —

Signature —

I refuse to sign No

Step 9 — Summary & Signature

1. Patient Information

Closest Relative

Dentist

General Information

2. Financial Responsibility

3. Insurance Information

Dental Insurance

Medical Insurance

4. Medical Information

Physician

Other physicians/health care providers being seen now:

Medical History

Now or in the past, have you had:

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

Dental History

Now or in the past, have you had:

Patient Health Information

Family Medical History

5. Release and Waiver

6. Medical History Updates or Changes

Change 1

7. Adult STOP – BANG Sleep Questionnaire

STOP

BANG

8. Acknowledgement of Receipt of Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES