Health History Form
Welcome! Our specialty is creating smiles and to do this we treat people, not just teeth. We care about your health and appreciate your time in completing this Health History form.
Today's Date
Patient's Name
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
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
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
no
yes
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
If you answer "yes" to any of the following questions, please explain in the space provided:
yes
no
Are you currently under the care of a physician?
yes
no
Are you presently taking any medication?
yes
no
Have you ever been advised that antibiotics should be taken prior to dental procedures? If so, why?
yes
no
Are you allergic to any medication?
yes
no
Have you had any major operations?
yes
no
Have you ever been involved in a serious accident?
Please check any of the following that you have had or currently have:
yes
no
AIDS/HIV
yes
no
Asthma/Hayfever
yes
no
Drug/Alcohol Abuse
yes
no
Heart Problems/Murmur
yes
no
Mitral Valve Prolapse
yes
no
Allergies
yes
no
Blood Disease
yes
no
Ear Infections
yes
no
Hepatitis
yes
no
Sinus Problems
yes
no
Anemia
yes
no
Cancer
yes
no
Epilepsy/Seizures
yes
no
High Blood Pressure
yes
no
Tuberculosis
yes
no
Arthritis
yes
no
Diabetes
yes
no
Fever Blisters/Herpes
yes
no
Low Blood Pressure
yes
no
Tumor
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?
If you answer "yes" to any of the following questions, please explain in the space provided:
yes
no
Have you ever been evaluated for orthodontic treatment?
yes
no
Have you or anyone in your family ever had any orthodontic treatment?
yes
no
Have you ever experienced any unfavorable reaction to dentistry?
yes
no
Do you have any type of speech problem?
yes
no
Do you have any type of thumb, finger, or tongue thrust problem?
yes
no
Do you have any difficulty chewing?
yes
no
Do you have any pain/tenderness in your face or jaw joints?
yes
no
Have you ever had any treatment for a TMJ (jaw joint) problem?
yes
no
Are you aware of your jaw clicking or popping?
yes
no
Have you ever been told that you grind your teeth?
yes
no
Do you clench your teeth?
yes
no
Do you have tension or migraine headaches?
yes
no
Have you ever had periodontal (gum) disease?
yes
no
Have you ever had any serious injuries to your face or teeth?
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
Security Captcha
If printing form, please remember to bring completed form with you to your first visit.
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