Adult Medical History Form
Date
Patient's First Name
Patient's Last Name
Birth Date
Email
Please Check All That Apply
Yes
No
DK
Are you pregnant?
Yes
No
DK
Are you taking birth control?
Yes
No
DK
Are you anticipating becoming pregnant?
Yes
No
DK
Birth defects or hereditary problems?
Yes
No
DK
Bone fractures, any major accidents?
Yes
No
DK
Rheumatoid or arthritic conditions?
Yes
No
DK
Endocrine or thyroid problems?
Yes
No
DK
Kidney Problems?
Yes
No
DK
Diabetes?
Yes
No
DK
Cancer or being treated for tumor?
Yes
No
DK
Stomach ulcer or hyperactivity?
Yes
No
DK
Polio, Mononucleosis, tuberculosis, pneumonia?
Yes
No
DK
Problems of the immune system?
Yes
No
DK
AIDS or HIV positive?
Yes
No
DK
Sexually transmitted disease?
Yes
No
DK
Fainting spells, seizures, epilepsy, or neurologic disease?
Yes
No
DK
Vision, hearing, tasting or speech difficulties?
Yes
No
DK
Mental health or behavioral problems?
Yes
No
DK
Loss of weight recently, poor appetite?
Yes
No
DK
High or low blood pressure?
Yes
No
DK
Easily tired?
Yes
No
DK
Any history of antibiotic premedication prior to dental appointments?
Yes
No
DK
Do you have osteoporosis?
Yes
No
DK
Are you taking or ever taken medication for Osteoporosis (bisphosphohates)?
Yes
No
DK
Chest pain, shortness of breath, swelling ankles?
Yes
No
DK
Heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects or rheumatic heart?
Yes
No
DK
Skin disorder?
Yes
No
DK
Do you have a normal and good diet?
Yes
No
DK
Frequent headaches, colds or sore throats?
Yes
No
DK
Any history of speech problems?
Yes
No
DK
Eye, ear, nose, throat condition?
Yes
No
DK
Hayfever, asthma, sinus trouble, hives?
Yes
No
DK
Tonsil or adenoid conditions?
Yes
No
DK
Allergies?
Yes
No
DK
Drug reactions?
Yes
No
DK
Are you taking medication, nutrient supplements or prescription medicine?
Please Name Them
Yes
No
DK
Do you currently have or ever had substance abuse problem?
Yes
No
DK
Operations?
Yes
No
DK
Hospitalized?
What were you hospitalized for?
Yes
No
DK
Other physical problems or symptoms?
Yes
No
DK
Being treated by another health care professional?
Yes
No
DK
Are you in good health?
Date of the most recent physical exam?
DENTAL HISTORY
Yes
No
DK
Chipped or ortherise injured permanent teeth?
Yes
No
DK
Teeth sensitive to hot or cold: teeth throb or ache?
Yes
No
DK
Jaw fractures, cysts, mouth infections?
Yes
No
DK
Dead Teeth, root canal, mouth odor?
Yes
No
DK
Bleeding gums, bad taste, mouth odor?
Yes
No
DK
Periodontal Gum Problems?
Yes
No
DK
Food impaction between teeth?
Yes
No
DK
Gum Boils, frequent canker sores, cold sores?
Yes
No
DK
Thumb, finger sucking habit, tongue thrusting?
Yes
No
DK
Abnormal swallowing habit, tongue thrusting?
Yes
No
DK
Mouth breathing habit, snoring, difficulty in breathing?
Yes
No
DK
Tooth grinding, jaw clenching, clicking, locking?
Yes
No
DK
Do you experience any pain or soreness in the muscles of your face or around the ears?
Yes
No
DK
Any pain in jaw or ringing in the ears?
Yes
No
DK
Difficulty encountered in chewing or jaw opening?
Yes
No
DK
History of supernumerary (extra) or congenitally missing teeth?
Yes
No
DK
Have any permanent teeth been removed?
Yes
No
DK
Aware of loose, broken or missing restorations (fillings)?
Yes
No
DK
Any teeth irritating cheek, lip, tongue, palate?
Yes
No
DK
Have you ever had Orthodontic treatment or worn a retainer or bite plate?
Recent Physical Exam Date
Yes
No
DK
Have you recently been under another dentist's care?
If so, which specialist?
Yes
No
DK
Hepatitis, jaundice, or liver problems?
Yes
No
DK
Excessive bleeding, black and blue tendency anemia or bleeding disorder?
Yes
No
DK
Have you ever had Periodontal gum treatment?
Yes
No
DK
Concerned about spaced, crooked, protruding teeth?
Yes
No
DK
Aware or concerned about under or over developed jaw?
Yes
No
DK
Any relatives with similar tooth or jaw relationships?
Yes
No
DK
Any wisdom tooth problems?
Yes
No
DK
Have you had any serious trouble associated with any previous dental treatment?
Present Weight
Present Height
What is your primary concern? Why are you here?
Date of most recent dental examination
How often do you brush?
How often do you floss?
Realizing that successful treatment greatly depends upon the patients complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment? I have read and understand the above questions. 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. If there are any changes later to this history record or medical / dental status, I will so inform this practice.
Signature of Patient
date
MEDICAL HISTORY UPDATES OR CHANGES, DATES, COMMENTS
Location
Phoenix Office
Chandler Office
or
Be sure to bring the printed form with you on your first visit.
