Medical Dental History Form for Adult Patient

PATIENT

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:

Have you had allergies or reactions to any of the following:

DENTAL HISTORY

Now or in the past, have you had:

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