MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS
Other physicians/health care providers being seen now:
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).
Now or in the past, have you had: (all fields are required)
Have you had allergies or reactions to any of the following:
Now or in the past, have you had: (all fields required)
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription
medicines, including fluoride supplements that you take.
Have your parents or siblings ever had any of the following health problems?
If so, please explain.
MEDICAL HISTORY UPDATES OR CHANGES
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.