form header
Medical Dental History Form for Adult Patient
Which office?
Patient
Gender

Closest Relative

Dentist

Physician
Other physicians/health care providers being seen now:

General Information

Financial Responsibility

Dental Insurance

Medical Insurance

Medical History
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (DKU).

Now or in the past, have you had:
BIRTH DEFECTS OR HEREDITARY PROBLEMS?

BONE FRACTURES, OR MAJOR INJURIES?

ANY INJURIES TO FACE, HEAD, NECK?

ARTHRITIS OR JOINT PROBLEMS?

CANCER, TUMOR, RADIATION TREATMENT OR CHEMOTHERAPY?

ENDOCRINE OR THYROID PROBLEMS?

DIABETES OR LOW SUGAR?

KIDNEY PROBLEMS?

IMMUNE SYSTEM PROBLEMS?

STOMACH ULCER, HYPERACIDITY, ACID REFLUX?

HISTORY OF OSTEOPOROSIS?

GONORRHEA, SYPHILIS, HERPES, SEXUALLY TRANSMITTED DISEASES?

AIDS OR HIV POSITIVE?

HEPATITIS, JAUNDICE OR OTHER LIVER PROBLEMS?

POLIO, MONONUCLEOSIS, TUBERCULOSIS, PNEUMONIA?

SEIZURES, FAINTING SPELLS, NEUROLOGIC PROBLEM?

MENTAL HEALTH DISTURBANCE OR DEPRESSION?

HISTORY OF EATING DISORDER (ANOREXIA, BULIMIA)?

FREQUENT HEADACHES OR MIGRAINES?

HIGH OR LOW BLOOD PRESSURE?

EXCESSIVE BLEEDING OR BRUISING TENDENCY, ANEMIA?

CHEST PAIN, SHORTNESS OF BREATH, TIRE EASILY, SWOLLEN ANKLES?

HEART DEFECTS, HEART MURMUR, RHEUMATIC HEART DISEASE?

ANGINA, ARTERIOSCLEROSIS, STROKE OR HEART ATTACK?

SKIN DISORDER (OTHER THAN COMMON ACNE)?

DO YOU EAT A WELL-BALANCED DIET?

VISION, HEARING, OR SPEECH PROBLEMS?

FREQUENT EAR INFECTIONS, COLDS, THROAT INFECTIONS?

ASTHMA, SINUS PROBLEMS, HAYFEVER?

TONSIL OR ADENOID CONDITION?

DO YOU FREQUENTLY BREATHE THROUGH YOUR MOUTH?


Have you had allergies or reactions to any of the following:
LOCAL ANESTHETICS (NOVOCAINE, LIDOCAINE, XYLOCAINE)

LATEX (GLOVES, BALLOONS)

ASPIRIN

IBUPROFIN (MOTRIN, ADVIL)

PENICILLIN

OTHER ANTIBIOTICS

METALS (JEWELRY, CLOTHING SNAPS)

ACRYLICS

PLANT POLLENS

ANIMALS

FOODS

OTHER SUBSTANCES

Dental History
Have you had allergies or reactions to any of the following:
PERMANENT OR EXTRA (SUPERNUMERARY) TEETH REMOVED?

SUPERNUMERARY (EXTRA) OR CONGENITALLY MISSING TEETH?

CHIPPED OR INJURED PRIMARY OR PERMANENT TEETH?

ANY SENSITIVE OR SORE TEETH?

BLEEDING GUMS, BAD TASTE OR MOUTH ODOR?

JAW FRACTURES, CYSTS, INFECTIONS?

JAW FRACTURES, CYSTS, INFECTIONS?

ANY TEETH TREATED WITH ROOT CANALS OR PULPOTOMIES?

“GUM BOILS,” FREQUENT CANKER SORES OR COLD SORES?

HISTORY OF SPEECH PROBLEMS OR SPEECH THERAPY?

DIFFICULTY BREATHING THROUGH NOSE?

FOOD IMPACTION BETWEEN THE TEETH?

MOUTH BREATHING HABIT OR SNORING AT NIGHT?

HISTORY OF SPEECH PROBLEMS?

FREQUENT ORAL HABITS (SUCKING FINGER, CHEWING PEN, ETC.)?

TEETH CAUSING IRRITATION TO LIP, CHEEK OR GUMS?

ABNORMAL SWALLOWING (TONGUE THRUST)?

TOOTH GRINDING OR CLENCHING?

CLICKING, LOCKING IN JAW JOINTS?

SORENESS IN JAW MUSCLES OR FACE MUSCLES?

RINGING IN EARS, DIFFICULTY IN CHEWING OR OPENING JAW?

HAVE YOU EVER BEEN TREATED FOR “TMJ” OR “TMD” PROBLEMS?

ANY BROKEN OR MISSING FILLINGS?

ANY SERIOUS TROUBLE ASSOCIATE WITH PREVIOUS DENTAL TREATMENT?

HAVE YOU EVER BEEN DIAGNOSED WITH GUM DISEASE OR PYORRHEA?

HAVE YOU EVER HAD AN ORTHODONTIC CONSULTATION OR TREATMENT BEFORE NOW?

Patient Health Information
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.
Women:

Family Medical History
Have the parents or siblings ever had any of the following health problems? If so, please explain.

Release and Waiver
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.

Medical History Updates