Adult Health History Form
Who can we thank for referring you to our office if other than your dentist?
Patient Name
Patient Nickname
Patient Birth Date
Patient Age
Sex
Male
Female
Patient Home Address
Home Phone
General Dentist
Office Phone
List any known allergies:
Sensitivity to latex?
Yes
No
Responsible Party Information
This office reserves the right to verify the credit status of potential patients seeking payment terms.
Patient Full Name
Marital Status
Married
Divorced
Widowed
Single
Partnership
Address
Home Phone
Work Phone
Cell Phone
Email Address
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date:
Employer
Occupation
Years Employed
Spouse (Partner) Name
Marital Status:
Married
Divorced
Widowed
Single
Partnership
Address
Home Phone
Work Phone
Cell Phone
Email Address
SSN (Must be provided to verify orthodontic insurance coverage)
Birth Date:
Employer
Occupation
Years Employed
Dental Insurance Information
(Please provide copy of insurance card to office)
Do you have DENTAL Insurance?
Yes
No
If yes, Primary Insurance Company:
Insurance Company Address
Insurance Company Phone
Name of Employer
Group No.
ID #
Employee Name
Date of Birth
Employee Home Address (If different than patient)
Employee relationship to patient
Employee Social Security #
Upload photo of front and back of insurance card
Do you have Secondary Insurance?
Yes
No
Secondary Insurance Company
Insurance Co. Address
Insurance Co. Phone
Name of Employer
Group No.
ID #
Employee Name
Date of Birth
Employee Home Address (if different than patient)
Employee relationship to patient
Employee Social Security #
Upload photo of front and back of insurance card
Name of emergency contact (not living in your home)
Phone
Complete Address:
Relationship
Medical History
Is this patient in Good health?
Yes
No
Does this patient have a history of major illness?
Yes
No
Has patient been under the care of a physician for a major illness?
Yes
No
List any known allergies:
Sensitivity to latex?
Yes
No
Do you have or have had a history with any of the following?
Asthma
Diabetes
Pneumonia
Heart Probs.
Rheumatic Fever
Bone Disorders
Hepatitis
Cancer
Anemia
Epilepsy
Nervous Disorder
Tuberculosis
ADD/ADHD
AIDS/HIV
High Blood Pressure
Prolonged Bleeding
Fainting or Dizziness
Liver Involvement
Kidney Involvement
Endocrine Problems
Veneral Disease
If yes to any of the above, please explain:
Have you tonsils and adenoids been removed?
Yes
No
If yes, what age?
Has patient reached puberty?
Yes
No
If male, has voice changed?
Yes
No
If female, has menstruation started?
Yes
No
If female, are you pregnant?
Yes
No
TMJ/TMD Symptoms
Yes
Yes
No
History of headaches?
Yes
No
Any other medical concerns?
General
Previous orthodontic treatment?
Yes
No
What concerns you most about your teeth and facial appearance?
Have other members of your family had orthodontic treatment?
Has anyone in your family been seen in our office? Name(s)
Does anyone in your family have a similar dental problem?
List Children name(s) and age(s)
Dental History
Have there been injuries to the face, mouth or teeth?
Yes
No
Has the patient ever sucked a thumb or finger?
Yes
No
If yes, until what age?
Does the patient have any speech problems?
Yes
No
Have you been informed of any missing or extra teeth?
Yes
No
Has an orthodontist been consulted previously?
Yes
No
Has either parent or patient had orthodontic treatment?
Yes
No
Chief concern:
The above information is correct to the best of my knowledge.
Signature:
Date Submitted: