Adult Health History Form

DATE BIRTHDATE AGE
MALE FEMALE

FIRST AND LAST NAME EMAIL PREFERRED NAME
HOME PHONE ADDRESS SSN
CELL PHONE CITY STATE ZIP
WHO MAY WE THANK FOR REFFERING YOU? OTHER FAMILY MEMBERS SEEN BY US
PRIMARY REASON FOR YOUR VISIT:

MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED SEPARATED
I REQUEST APPOINTMENT REMINDERS VIA: EMAIL TEXT BOTH NONE

YOUR EMPLOYER BUSINESS ADDRESS OCCUPATION
WORK PHONE CITY STATE ZIP
HOW LONG AT CURRENT EMPLOYER DRIVER'S LICENSE NUMBER

RESPONSIBLE PARTY (If different from patient)
RESPONSIBLE PARTY NAME BIRTHDATE SSN DRIVER'S LICENSE #
HOME PHONE ADDRESS CELL PHONE
CITY STATE ZIP
RELATION RESPONSIBLE PARTY EMPLOYER BUSINESS ADDRESS OCCUPATION
WORK PHONE CITY STATE ZIP

SPOUSE INFORMATION
SPOUSE'S NAME EMPLOYER OCCUPATION CELL PHONE NUMBER
WORK PHONE NUMBER BIRTH DATE

EMERGENCY CONTACT
NAME OF CLOSEST RELATIVE NOT LIVING WITH YOU RELATION
HOME PHONE NUMBER CELL PHONE NUMBER WORK PHONE NUMBER

INSURANCE INFORMATION (PRIMARY)
DO YOU HAVE INSURANCE COVERAGE FOR ORTHODONTIC TREATMENT? YES NO
DO YOU HAVE INSURANCE COVERAGE FOR DENTISTRY? YES NO
EMPLOYEE NAME ID NUMBER BIRTHDATE
INSURANCE COMPANY #1 EMPLOYER GROUP NUMBER

INSURANCE INFORMATION (SECONDARY)
DO YOU HAVE INSURANCE COVERAGE FOR ORTHODONTIC TREATMENT? YES NO
DO YOU HAVE INSURANCE COVERAGE FOR DENTISTRY? YES NO
EMPLOYEE NAME ID NUMBER BIRTHDATE
INSURANCE COMPANY EMPLOYER GROUP NUMBER

HEALTH QUESTIONNAIRE
The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.

PHYSICIAN NAME DATE OF LAST VISIT

Are you pregnant? YES NO
If YES please specify:

Are you taking any medication? YES NO
If YES please specify:

Are you allergic to any medication? YES NO
If YES please list:

Do you have a history of a major illness? YES NO
If YES please specify:

Have you had any major operations? YES NO
If YES please specify:

Have there been any injuries to the face, mouth, teeth or chin? YES NO
If YES please specify:

Have you had a history of any of the following?
Asthma Abnormal Bleeding/Hemophilia Epilepsy Hay Fever
Nervous Disorders Herpes Tuberculosis ADD/ADHD
Gastrointestinal Disorders Rheumatic Fever Anemia Sexually Transmitted Disease
Handicap/Disability Radiation/Chemotherapy Sickle Cell Hearing Impairment
Kidney Problems HIV Cancer Heart Murmur
Liver Problems Low Blood Pressure Congenital Heart Defect Hepatitis
Mitral Valve Prolapse High Blood Pressure Stroke Sinus Problems
Ulcers Drug Abuse
OTHER Conditions not listed:
Comments:

Have you had any serious illness, operation, or been hospitalized within the past 5 years? YES NO
If so, what was the illness or problem?

Do you have allergies to any of the following?
Aspirin Erythromycin Penicillin Codeine
Jewelry/Metals Tetracycline Dental Anesthetics Latex
OTHER allergies not listed:
DENTAL HISTORY
FAMILY DENTIST DATE OF LAST CLEANING
Are you presently in any dental pain? Explain: YES NO
If YES please specify:

Have you ever experienced any unfavorable reaction to dentistry? YES NO
If YES please specify:

Have you ever lost or chipped any teeth? YES NO
Is any part of your mouth sensitive to temperature or pressure? YES NO
Do your gums bleed when you brush? YES NO
Do you have any type of thumb or tongue habit? YES NO
Have you ever seen an orthodontist? If yes, who and when? YES NO
If YES, who and when?:

Do your teeth or jaws ever feel uncomfortable when you awake in the morning? YES NO
Are you aware of your jaw clicking or popping? YES NO
If YES,Explain:

Are you aware of clenching your teeth during the day? YES NO
Have you ever been told that you grind your teeth? YES NO
Do you have tension headaches? YES NO
Have you ever experienced chronic ringing in your ears? YES NO
Do you have any missing or extra permanent teeth? YES NO
Do you have any speech problems? YES NO
Your current dental health is: GOOD FAIR POOR
Acknowledgment of Privacy Policy

I am aware that a copy of this office's Notice of Privacy Practices is available at request.
I Agree: YES NO
AUTHORIZATION

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

SIGNATURE OF PATIENT OR PARENT/LEGAL GUARDIAN DATE


   or  
If printing form, please remember to bring completed form with you to your first visit.


www.jerniganortho.com