Medical History Form

Medical History Form

The following patient information and health history is to be completed by adult patients or a parent/guardian of a minor.
Patient’s Name
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Age
Patient's Sex (Assigned at Birth)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
Emails are only used for appointment and patient communication, your email will only be store internally.
Marital status of parents (if patient is a minor) or yourself
Who will be the person finacially responsible for this patient?
What is their relationship to the patient?
What is the name of you/your families dentist?
Dentist Name and/or Office Name
When was the last time you/the patient was last seen by a dentist?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you hear about us?
Has the patient been seen by another orthodontist?
What orthodontist did you/they see and when?
Names and ages of other children in family
Have they had any orthodontic treatment?
If so, with whom and when?
Chief Complaint (i.e. why do you want orthodontic treatment)?
Have there been any accidents that damaged the face, teeth, or jaws?
Have you been informed of any missing or extra permanent teeth?
Is there any treatment that has been recommended by the patient’s dentist?
Brush teeth daily?
Does the patient:
Is the patient currently in good physical Health?
Has the patient experienced any of the following medical problems or conditions?
Abnormal bleeding, hemophilia, or anemia
ADD/ADHD
Alcohol or Drug Abuse
Any hospital stays or operations
Arthritis
Artificial Bones/Joints/Valves
Asthma, hay fever, or sinusitis
Autism or Autism Spectrum Disorders
Autoimmune disorders (lupus, etc.)
Cancer, chemotherapy, or radiation
Congenital Heart Defect
Diabetes
Digestive problems, ulcers, colitis, etc.
Dizziness or fainting spells
Ear or eye trouble other than corrective lenses
Epilepsy, seizures, or convulsions
Frequent headaches
Handicaps or disabilities
Heart problems, heart murmur, or mitral valve prolapse
Pre-medication required for dental procedures?
Hepatitis, jaundice, or liver problems
High or low blood pressure
HIV+ or AIDS
Kidney or bladder problems
Pacemaker
Periodontal or gum disease
Pregnancy (current)
Problems with Novocain or anesthetics
Psychiatric problems
Respiratory problems or disorders
Rheumatic/Scarlet Fever
Skin Problems
Stroke
Thyroid or endocrine problems
Tuberculosis (TB)
Venereal Disease
Please list any other serious medical problem
Any allergies (ie: Latex, Nickel/Metal, etc)?
Please list any allergies
Please list any medications
Dental Insurance Information
Patient’s or Father’s Name
Address
Telephone
Format: (000) 000-0000.
SSN
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Dental Insurance Company
Dental Insurance ID
Spouse’s or Mother’s Name
Address
Telephone
Format: (000) 000-0000.
SSN
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employer
Dental Insurance Company
Dental Insurance ID
Preferred Office Location
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes to the patient’s (self or child’s) medical status.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Medical History Form

Has the patient experienced any of the following medical problems or conditions?

Dental Insurance Information