Medical Form (for adults)

To better understand your dental health needs and your feelings towards orthodontics, please complete this form and submit it prior to your first appointment. Thank you for helping us plan the best care for you.
 

Patient Information

Patient's name:
Last:    First:  MI:
I prefer to be called:

Home address:
Street:   City:
State:   ZIP:  
Male:    Female:     Patient's age:  

Home phone:   Business phone:
SS#   Birthdate:
E-mail address:   Occupation:
Employed by: (give address if used for correspondence)

Best time to reach you: (when and where)
Your dentist(s):
Your physician(s):
Your interests and activities:
Other family members seen by us:
Preferred appointments:
Whom may we thank for referring you?

Spouse's name:
Last:   First:   MI:
Business phone:
Spouse employed by:
Occupation:

Dental History & Status
Have you ever had: Yes | No
●  Any injured or broken teeth?

   

●  Any unusual reaction to dental medications?

   

●  Any injuries to your head or face?

   

●  Any problems with eating, chewing or swallowing?

   

●  Any dental or facial pain?

   

●  Any jaw joint noise or pain when opening, closing or chewing?

   

●  A tooth clenching or grinding habit?

   

●  Soreness in the muscles of your face?

   

●  Difficulty breathing with your mouth closed?

   

●  Swellings or growths in your mouth?

   

●  Gums that bleed when brushing your teeth?

   

●  Treatment from a periodontist, endodontist or oral surgeon?

   

        When:     Whom:
●  Previous orthodontic treatment or consultation?

   

        When:     Whom:
●  Are you dissatisfied about the appearance of your teeth?
●  Are you especially concerned about orthodontic treatment?
●  Is there other information we should know?

Medical History
  Yes | No
●  Are you presently in good health?

   

    Date of last physical exam:
●  Are you being treated by a physician?

   

    For what?
●  Have you been hospitalized or had a major illness in the last 5 years?

   

    Please explain:
●  Are you taking any prescription or non-prescription medications, or nutritional supplements?

   

    Please list:
●  Do you have any allergies to drugs or medicines?

   

    Please list:
●  Are there any congenital problems?

   

    Please list:
●  Do you drink alcohol?

   

    If yes, how often?
●  Do you use tobacco?

   

    If yes, how much and what form?
●  Have you had recurrent sores in your mouth or on other parts of your body?

   

●  Did you ever have a drug transfusion, particularly prior to March 1985?

   

●  For women: Are you pregnant or anticipating pregnancy?

   

    If yes, give due date:
●  Are you taking hormonal supplements?

   

Have you ever been diagnosed or treated for the following? Yes No
●  AIDS or HIV Positive?

   

●  Anemia

   

●  Arthritis

   

●  Bone disease

   

●  Breathing problems

   

●  Cancer or been treated for tumor

   

●  Cerebral palsy

   

●  Diabetes

   

●  Dizziness/fainting spells

   

●  Emotional problems

   

●  Epilepsy or neurologic problems

   

●  Glaucoma

   

●  Heart disorder or defects

   

●  Hepatitis

   

        If yes, hepatitis type:
●  Kidney problems

   

●  Hearing, tasting, speech difficulties

   

●  Immune system problems

   

●  Substance abuse problems

   

●  Liver problems

   

●  High or Low blood pressure

   

●  Multiple sclerosis

   

●  Prolonged bleeding

   

●  Respiratory allergies

   

●  Rheumatic fever

   

●  Scarlet fever

   

●  Shortness of breath

   

●  Sickle cell anemia

   

●  Sinus problems

   

●  Stomach ulcers

   

●  Stroke

   

●  Thyroid or endocrine problem

   

●  Tuberculosis

   

●  Other, please specify:
●  Is there any other information concerning your health the doctors should be aware of?

Employee/Subscriber Information (if you have orthodontic insurance)
Employee subscriber name:    SS#
Employed by:    Subscriber date of birth:
Subscriber's relationship to patient:
Ortho insurance company name:    Group #
Insurance company phone #

Any other comments?

If there are problems with the form, please contact the webmaster with details.