PATIENT HISTORY FORM (ADULT)

You may complete the Patient History form below and submit the data online. The form is Patient Medical Dental History (ADULT) Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant. Please fill out all items to your best knowledge. Fields marked with an asterisk (*) are required.

    PATIENT INFORMATION

  • MaleFemale
  • HomeCell
  • YesNo
  • HomeCellOther
  • YesNo

SPOUSE/EMERGENCY CONTACT INFORMAITON

  • Marital Status*SingleMarriedDivorcedWidowedSignificant Other

DENTAL INSURANCE INFORMATION

DENTAL HISTORY

  • How did you hear about our practice? AdInternetFamily or FriendPhysicianOther
  • Have you visited an orthodontist before? YesNo
  • Have your tonsils or adenoids been removed?YesNo
  • Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?YesNo
  • Do you have any missing or extra permanent teeth?YesNo
  • Have you ever had an injury to (select all that apply)?TeethMouthChinSelect All That Apply
  • Do you have speech problems?YesNo
  • Do your gums bleed? YesNo
  • Do you smoke? YesNo
  • Do you like your smile?YesNo
  • Do you currently or have you ever had any of the following habits (select all that apply)?
    Clenching/Grinding TeethMouth BreathingThumb/Finger SuckingLip Sucking/BitingNail BitingChewing/Eating Problem

MEDICAL HISTORY

  • Are you currently being treated by a physician?YesNo
  • Do you have any allergies/sensitivities to medications or latex?YesNo
  • Are you currently taking any prescription over-the-counter medications?YesNo
  • Have you had any serious illnesses or operations?YesNo
  • Have you ever had a blood transfusion?YesNo
  • Are you pregnant?YesNo
  • Nursing?YesNo
  • Are You Taking Medications For Osteoporosis?YesNo
  • If Yes Name Of Medication
  • Check if you have ever had any of the following?
    AnemiaArthritis RheumatismArtificial Heat ValvesArtificial JointsAsthmaBack ProblemsBlood DiseaseCancerChemical DependencyChemotherapyCirculatory ProblemsCortisone TreatmentsCough, PersistentCoughing BloodDiabetesEpilepsyFaintingGlaucomaHeadachesHeart MurmurHeart ProblemsHemophiliaHepatitisHigh Blood PressureHIV/AIDSJaw PainKidney DiseaseLiver DiseaseMitral Valve ProlapsePacemakerRadiation TreatmentRespiratory DiseaseRheumatic FeverScarlet FeverShortness of BreathSkin RashStokeSwelling of Feet or AnklesThyroid ProblemsTobacco HabitTonsillitisTuberculosisUlcerVenereal Disease

    AUTHORIZATION