Health History Form

HEALTH HISTORY FORM

Today's Date

Patient's Name

Last

First

Middle

Nickname

Address

City

State

Zipcode

Home Phone

Birthdate

School

Grade

Email Address

Responsible Party's email address

If minor, give parent/guardian name

How did you hear about our office?

Siblings/Children - Name & Age

Hobbies/Interests/Sports

RESPONSIBLE PARTY INFORMATION

Name

Last

First

Middle

Marital Status

Address

City

State

Zipcode

How long at this address?

Home Phone

Work Phone

Previous Address (if less than 3 yrs.)

City

State

Zipcode

Social Security #

Birthdate

Relationship to Patient

Employer

Occupation

Years Employed

Spouse's Name

Last

First

Middle

Relationship to Patient

Social Security #

Birthdate

Employer

Occupation

Years Employed

ORTHODONTIC INSURANCE INFORMATION

Insured's Name

SS # / Member ID

Insurance Company

Group Number

Phone Number

Do you have dual coverage? If yes, please complete the following secondary insurance info

Yes

No

Insured's Name

SS # / Member ID

Insurance Company

Group Number

Phone Number

EMERGENCY INFORMATION

Name of nearest relative not living with you

Complete Address

Phone Number

MEDICAL HISTORY

Physician

Date of Last Visit

Are you currently under the care of a physician?

Yes

No

If yes, please explain:

Are you presently taking any medication?

Yes

No

If yes, please explain:

Have you ever been advised that antibiotics should be taken prior to dental procedures? If so, why?

Yes

No

If yes, please explain:

Are you allergic to any medication?

Yes

No

If yes, please explain:

Have you had any major operations?

Yes

No

If yes, please explain:

Have you ever been involved in a serious accident?

Yes

No

If yes, please explain:

Please check any of the following that you have had or currently have:

AIDS/HIV

Yes

No

Diabetes

Yes

No

Allergies

Yes

No

Drug/Alcohol Abuse

Yes

No

Anemia

Yes

No

Ear Infections

Yes

No

Arthritis

Yes

No

Epilepsy/Seizures

Yes

No

Asthma/Hayfever

Yes

No

Fever Blisters/Herpes

Yes

No

Blood Disease

Yes

No

Heart Problems/Murmur

Yes

No

Cancer

Yes

No

Hepatitis

Yes

No

Are there any medical conditions we have not discussed that you feel we should be aware of?

DENTAL HISTORY

General Dentist

Date of Last Visit

What concerns you most about your teeth?

Have you ever been evaluated for orthodontic treatment?

Yes

No

If yes, please explain:

Have you or anyone in your family ever had any orthodontic treatment?

Yes

No

If yes, please explain:

Have you ever experienced any unfavorable reaction to dentistry?

Yes

No

If yes, please explain:

Do you have any type of speech problem?

Yes

No

If yes, please explain:

Do you have any type of thumb, finger, or tongue thrust problem?

Yes

No

If yes, please explain:

Do you have any difficulty chewing?

Yes

No

If yes, please explain:

Do you have any pain/tenderness in your face or jaw joints?

Yes

No

If yes, please explain:

Have you ever had any treatment for a TMJ (jaw joint) problem?

Yes

No

If yes, please explain:

Are you aware of your jaw clicking or popping?

Yes

No

If yes, please explain:

Have you ever been told that you grind your teeth?

Yes

No

If yes, please explain:

Do you clench your teeth?

Yes

No

If yes, please explain:

Do you have tension or migraine headaches?

Yes

No

If yes, please explain:

Have you ever had periodontal (gum) disease?

Yes

No

If yes, please explain:

Have you ever had any serious injuries to your face or teeth?

Yes

No

If yes, please explain:

BENEFITS OF ORTHODONTICS: AESTHETICS, HEALTH, & FUNCTION

Orthodontics is a service that provides an improvement in the appearance of the teeth, the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and there can be some movement of teeth and some change after treatment. Our office is committed to meeting or exceeding the standards of infection control as mandated by OSHA, the CDC and the ADA. We also abide by HIPPA guidelines, insuring that patient information is kept private.

I hereby state that I have read and understand the above paragraph and have truthfully, to the best of my ability, answered all the above questions.

Signature of Patient

Date