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Adult Health History Form
Gender
Marital Status
I request appointment reminders via:
Responsible Party (If different from patient)
Spouse Information
Emergency Contact
Insurance Information (Primary)
Do you have insurance coverage for orthodontic treatment?
Do you have insurance coverage for dentistry?
Insurance Information (Secondary)
Do you have insurance coverage for orthodontic treatment?
Do you have insurance coverage for dentistry?
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.

Are you pregnant?
Are you taking any medication?
Are you allergic to any medication?
Do you have a history of major illness?
Have you had any major operations?
Have there been any injuries to the face, mouth, teeth, or chin?
Have you had a history of any of the following:
Have you had any serious illness, operation, or been hospitalized within the past 5 years?
Do you have allergies to any of the following?
Dental History
Are you presently in any dental pain?
Have you ever experienced any unfavorable reaction to dentistry?
Have you ever lost or chipped any teeth?
Is any part of your mouth sensitive to temperature or pressure?
Do your gums bleed when you brush?
Do you have any type of thumb or tongue habit?
Have you ever seen an orthodontist?
Do your teeth or jaws ever feel uncomfortable when you awake in the morning?
Are you aware of your jaw clicking or popping?
Are you aware of clenching your teeth during the day?
Have you ever been told that you grind your teeth?
Do you have tension headaches?
Have you ever experienced chronic ringing in your ears?
Do you have any missing or extra permanent teeth?
Do you have any speech problems?
Your current dental health is:
Acknowledgment of Privacy Policy
I am aware that a copy of this office's Notice of Privacy Policy Practices is available at request. I Agree:
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.