MDHA

MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS

PATIENT

Date

First name*

Middle initial*

Patient's Last name*

Title*

Date of birth*

Sex*

Male Female

Social Security #*

Marital Status*

I prefer to be called

Home Address*

Zip Code*

Cell Phone

Home Phone

Work Phone

Occupation*

E-mail address*

Employer*

Who may we thank for the referral?

CLOSEST RELATIVE

Spouse or closest relative’s name(s)*

Title

Relationship to patient*

Address (if different than patient address)

Home phone

Cell phone

Work phone

DENTIST

Patient’s Dentist*

Last seen

Address, City, State*

Reason

Next appointment

Other dentists/dental specialists now being seen: Name

City, State

Reason

PHYSICIAN

Patient’s Physician*

City, State*

Reason

Next appointment

Most recent physical exam

Other physicians/health care providers being seen now:

Name

City, State

Reason

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.

FINANCIAL RESPONSIBILITY

Who is financially responsible for this account?

Address (if different from patients')

City, State, Zip

Home phone

Cell phone

E-mail address

Social Security #

Employer

Who will be responsible for bringing the patient to orthodontic appointments?

DENTAL INSURANCE

Primary policy holder’s full name

Birthdate

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes No Don't Know

Secondary policy holder’s full name

Birthdate

Social Security #

Relationship to patient

Address and phone (if not listed above)

Employer

Address

Insurance company

Group #

ID #

Does this policy have orthodontic benefits?

Yes No Don't Know

MEDICAL INSURANCE

Policy holder’s full name

Insurance company

Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. FOR THE FOLLOWING QUESTIONS MARK YES, NO, OR DON'T KNOW/UNDERSTAND (DK/U).

MEDICAL HISTORY

Now or in the past, have you had: (all fields are required)

Birth defects or hereditary problems?

Yes No dk/u

Bone fractures, or major injuries?

Yes No dk/u

Any injuries to face, head, neck?

Yes No dk/u

Arthritis or joint problems?

Yes No dk/u

Endocrine or thyroid problems?

Yes No dk/u

Diabetes or low sugar?

Yes No dk/u

Kidney problems?

Yes No dk/u

Cancer, tumor, radiation treatment or chemotherapy?

Yes No dk/u

Stomach ulcer, hyperacidity, acid reflux?

Yes No dk/u

Immune system problems?

Yes No dk/u

History of osteoporosis?

Yes No dk/u

Gonorrhea, syphilis, herpes, sexually transmitted diseases?

Yes No dk/u

AIDS or HIV positive?

Yes No dk/u

Hepatitis, jaundice or other liver problem?

Yes No dk/u

Polio, mononucleosis, tuberculosis, pneumonia?

Yes No dk/u

Seizures, fainting spells, neurologic problem?

Yes No dk/u

Mental health disturbance or depression?

Yes No dk/u

Vision, hearing, or speech problems?

Yes No dk/u

History of eating disorder (anorexia, bulimia)?

Yes No dk/u

High or low blood pressure?

Yes No dk/u

Excessive bleeding or bruising, anemia?

Yes No dk/u

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

Yes No dk/u

Heart defects, heart murmur, rheumatic heart disease?

Yes No dk/u

Angina, arteriosclerosis, stroke or heart attack?

Yes No dk/u

Skin disorder (other than common acne)?

Yes No dk/u

Do you eat a well-balanced diet?

Yes No dk/u

Frequent headaches or migraines?

Yes No dk/u

Frequent ear infections, colds, throat infections?

Yes No dk/u

Asthma, sinus problems, hayfever?

Yes No dk/u

Tonsil or adenoid condition?

Yes No dk/u

Do you frequently breathe through your mouth?

Yes No dk/u

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

Local anesthetics (novocaine, lidocaine, xylocaine)

Yes No dk/u

Latex (gloves, balloons)

Yes No dk/u

Aspirin

Yes No dk/u

Ibuprofen (Motrin, Advil)

Yes No dk/u

Penicillin

Yes No dk/u

Other antibiotics

Yes No dk/u

Metals (jewelry, clothing snaps)

Yes No dk/u

Acrylics

Yes No dk/u

Plant pollens

Yes No dk/u

Animals

Yes No dk/u

Foods

Yes No dk/u

Other substances

Yes No dk/u

DENTAL HISTORY

Now or in the past, have you had: (all fields required)

Permanent or extra (supernumerary) teeth removed?

Yes No dk/u

Supernumerary (extra) or congenitally missing teeth?

Yes No dk/u

Chipped or injured primary or permanent teeth?

Yes No dk/u

Any sensitive or sore teeth?

Yes No dk/u

Bleeding gums, bad taste or mouth odor?

Yes No dk/u

Jaw fractures, cysts, infections?

Yes No dk/u

Any teeth treated with root canals or pulpotomies?

Yes No dk/u

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

Yes No dk/u

History of speech problems or speech therapy?

Yes No dk/u

Difficulty breathing through nose?

Yes No dk/u

Food impaction between the teeth?

Yes No dk/u

Mouth breathing habit or snoring at night?

Yes No dk/u

History of speech problems?

Yes No dk/u

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

Yes No dk/u

Teeth causing irritation to lip, cheek or gums?

Yes No dk/u

Abnormal swallowing (tongue thrust)?

Yes No dk/u

Tooth grinding or clenching?

Yes No dk/u

Clicking, locking in jaw joints?

Yes No dk/ u

Soreness in jaw muscles or face muscles?

Yes No dk/u

Ringing in ears, difficulty in chewing or opening jaw?

Yes No dk/u

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

Yes No dk/u

Any broken or missing fillings?

Yes No dk/u

Any serious trouble associate with previous dental treatment?

Yes No dk/u

Have you ever been diagnosed with gum disease or pyorrhea?

Yes No dk/ u

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

Yes No dk/u

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Have you ever taken any medications to strengthen your bones? Please describe

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?

Yes No

Are you trying to become pregnant?

Yes No

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain.

Bleeding disorders

Diabetes

Arthritis

Severe allergies

Unusual dental problems

Jaw size imbalance

Other family medical conditions?

MEDICAL HISTORY UPDATES OR CHANGES

Changes

Patient Signature

Date

Dental Staff Signature

Date

Changes

Patient Signature

Date

Dental Staff Signature

Date

Changes

Patient Signature

Date

Dental Staff Signature

Date

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.