CONFIDENTIAL

Medical Dental History Form for Adult Patients

PATIENT
Date Patient's Last name Title Mr. Mrs. Sin$le First name Middle initial Ms. Miss. Female Married Dr. Separated Other Di%orced I prefer to be called &ido'ed Social Sec rit! " # #

Birth date Sex: Male Marital Stat s (ome address

)it!* State* +ip code

(ome phone ,- # )ell phone ,- # &or. phone ,- # /#mail address,es- Occ pation /mplo!er

CLOSEST RELATI E
Spo se or closest relati%es name,s- Title Mr. Mrs. Ms. Miss. Dr. Other 0elationship to patient 1ddress (if different than patient address) (ome phone ,- # )ell phone ,- # &or. phone ,- #

DENTIST
Patient2s Dentist 1ddress* )it!* State Last seen 0eason 3ext appointment Other dentists4dental specialists no' bein$ seen: 3ame )it!* State 0eason

PH!SICIAN
Patient2s Ph!sician )it!* State Last seen 0eason 3ext appointment Most recent ph!sical exam Other ph!sicians4health care pro%iders bein$ seen no': 3ame )it!* State 0eason 3ame )it!* State 0eason 6
(istor! Form 5 1d lt 5 67478

"ENERAL INFORMATION
&hat concerns !o abo t !o r teeth9 &ho s $$ested that !o mi$ht need orthodontic treatment9 &h! did !o select o r office9 (a%e !o had an! pre%io s orthodontic treatment9 Please describe (a%e an! other famil! members been treated in this office9 Please name them. Do !o thin. that an! of !o r 'or. or leis re acti%ities affect !o r teeth or :a's9 Please explain.

FINANCIAL RESPONSI#ILIT!
&ho is financiall! responsible for this acco nt9 1ddress ,if different from page 1- )it!* State* +ip (ome phone ,- # )ell phone ,- # /#mail address,es- Social Sec rit! " # # /mplo!er: &ho 'ill be responsible for brin$in$ the patient to orthodontic appointments9

DENTAL INS$RANCE
Primar! polic! holder2s f ll name Birthdate Social Sec rit! " # # 0elationship to patient 1ddress and phone ,if not listed abo%e- /mplo!er 1ddress Ins rance compan! ;ro p " ID " Does this polic! ha%e orthodontic benefits9 <es 3o Don2t .no'

Secondar! polic! holder2s f ll name Birthdate Social Sec rit! " # # 0elationship to patient 1ddress and phone ,if not listed abo%e- /mplo!er 1ddress Ins rance compan! ;ro p " ID " Does this polic! ha%e orthodontic benefits9 <es 3o Don2t .no'

MEDICAL INS$RANCE
Polic! holder2s f ll name

Ins rance compan!

(istor! Form 5 1d lt 5 67478

!our ans%ers are for office records only& and are confidential' A t(orou)( medial (istory is essential to a com*lete ort(odontic e+aluation' For the following questions mark yes, no, or don't know/understand (dk/u).

MEDICAL HISTOR!
No% or in t(e *ast& (a+e you (ad,
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u Birth defects or hereditar! problems9 Bone fract res* or ma:or in: ries9 1n! in: ries to face* head* nec.9 1rthritis or :oint problems9 /ndocrine or th!roid problems9 Diabetes or lo' s $ar9 >idne! problems9 )ancer* t mor* radiation treatment or chemotherap!9 Stomach lcer* h!peracidit!* acid refl x9 Imm ne s!stem problems9 (istor! of osteoporosis9 ;onorrhea* s!philis* herpes* sex all! transmitted diseases9 1IDS or (I? positi%e9 (epatitis* :a ndice or other li%er problem9 Polio* monon cleosis* t berc losis* pne monia9 Sei@ res* faintin$ spells* ne rolo$ic problem9 Mental health dist rbance or depression9 ?ision* hearin$* or speech problems9 (istor! of eatin$ disorder ,anorexia* b limia-9 (i$h or lo' blood press re9 /xcessi%e bleedin$ or br isin$* anemia9 )hest pain* shortness of breath* tire easil!* s'ollen an.les9 (eart defects* heart m rm r* rhe matic heart disease9 1n$ina* arteriosclerosis* stro.e or heart attac.9 S.in disorder ,other than common acne-9 Do !o eat a 'ell#balanced diet9 FreA ent headaches or mi$raines9 FreA ent ear infections* colds* throat infections9 1sthma* sin s problems* ha!fe%er9 Tonsil r adenoid condition9 Do !o freA entl! breathe thro $h !o r mo th9 yes no d-.u yes yes yes no no no d-.u d-.u d-. u

DENTAL HISTOR!
No% or in t(e *ast& (a+e you (ad,
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-. u d-.u d-.u d-.u Permanent or extra ,s pern merar!- teeth remo%ed9 S pern merar! ,extra- or con$enitall! missin$ teeth9 )hipped or in: red primar! or permanent teeth9 1n! sensiti%e or sore teeth9 Bleedin$ $ ms* bad taste or mo th odor9 Ba' fract res* c!sts* infections9 1n! teeth treated 'ith root canals or p lpotomies9 C; m boils*D freA ent can.er sores or cold sores9 (istor! of speech problems or speech therap!9 Diffic lt! breathin$ thro $h nose9 Food impaction bet'een the teeth9 Mo th breathin$ habit or snorin$ at ni$ht9 (istor! of speech problems9 FreA ent oral habits ,s c.in$ fin$er* che'in$ pen* etc.-9 Teeth ca sin$ irritation to lip* chee. or $ ms9 1bnormal s'allo'in$ ,ton$ e thr st-9 Tooth $rindin$ or clenchin$9 )lic.in$* loc.in$ in :a' :oints9 Soreness in :a' m scles or face m scles9 0in$in$ in ears* diffic lt! in che'in$ or openin$ :a'9 (a%e !o e%er been treated for CTMBD or CTMDD problems9 1n! bro.en or missin$ fillin$s9 1n! serio s tro ble associate 'ith pre%io s dental treatment9 (a%e !o e%er been dia$nosed 'ith $ m disease or p!orrhea9 (a%e !o e%er had an orthodontic cons ltation or treatment before no'9

Ha+e you (ad aller)ies or reactions to any of t(e follo%in),

yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u d-.u Local anesthetics ,no%ocaine* lidocaine* x!locaineLatex ,$lo%es* balloons1spirin Ib profen ,Motrin* 1d%ilPenicillin Other antibiotics Metals ,:e'elr!* clothin$ snaps1cr!lics Plant pollens 1nimals Foods Other s bstances

(istor! Form 5 1d lt 5 67478

PATIENT HEALTH INFORMATION

List an! medication* n tritional s pplements* herbal medications or non#prescription medicines* incl din$ fl oride s pplements that !o ta.e. Medication Ta.en for Medication Ta.en for Medication Ta.en for (a%e !o e%er ta.en an! medications to stren$then !o r bones9 Please describe. Do !o or ha%e !o e%er had a s bstance ab se problem9 Do !o che' or smo.e tobacco9 (a%e !o noticed an! chan$es in !o r face or :a's9 1n! other ph!sical problems9 (o' often do !o br sh9 (o' often do !o floss9 &omen: 1re !o pre$nant9 <es

3o

1re !o tr!in$ to become pre$nant9

<es

3o

FAMIL! MEDICAL HISTOR!

(a%e !o r parents or siblin$s e%er had an! of the follo'in$ health problems9 If so* please explain. Bleedin$ disorders Diabetes 1rthritis Se%ere aller$ies Fn s al dental problems Ba' si@e imbalance Other famil! medical conditions9

RELEASE AND /AI ER

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health. Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG

MEDICAL HISTOR! $PDATES OR CHAN"ES

)han$es Patient Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG Dental Staff Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG )han$es Patient Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG Dental Staff Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG )han$es Patient Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG Dental Staff Si$nat re GGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGGG DateGGGGGGGGGGGGGGGGGGGGGGGGGGGG

H 1merican 1ssociation of Orthodontists =778