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Medical Dental History Form

Responsible Party Information
Spouse Information
Mailing
Residence
Own or Rent
Previous Address (if less than 3 years)

Patient Information

Insurance Information
Do you have dual coverage?
If yes:

Emergency Information

Medical History
Has the patient ever had any of the following:
Heart problem

Glaucoma

Respiratory problem

Kidney problem

Rheumatic fever

Hepatitis

Thyroid problem

Allergies

Epilepsy (seizure)

Prolonged bleeding

Arthritus

Diabetes

Major operation


Dental History
Has patient ever experienced any of the following:
Sensitive teeth

Root canal

Cleft lip/palate

Periodontal disease

Thumb sucking beyond age 4

Tounge thrust

Severe blow to teeth/jaw

Bleeding gums

Clicking/popping in jaw joint

Fractured teeth

Extraction of permanent teeth

Mouth breathing

Was your dentist going to send x-rays to us for this appointment?
Is patient on regular 6 month or yearly recall schedule with family dentist?
Has patient previously seen an orthodontist?
Has any other member of the family undergone orthodontic treatment?
Were you aware that an orthodontic problem might exist before being referred to our office?

By signing this form, you will consent to use and disclosure of your protected health information to communicate with your other healthcare providers and insurance company, carry out treatment, payment activities, and healthcare operations. I understand that where appropriate, credit bureau reports will be obtained.