Confidential medical dental history form

Date

PATIENT INFORMATION

Patient’s Last Name

First Name

Middle Initial

Date of Birth

Home Address

City, State, Zip

Home Phone

Cell Phone

Work Phone

E-mail

Social Security Number (required for insurance)

PARENT/LEGAL GAURDIAN IF PATIENT A MINOR, CLOSEST RELATIVE IF PATIENT IS ADULT

Last Name

First Name

Middle Initial

Date of Birth

Home Address (if different than patient)

City, State, Zip

Home Phone

Cell Phone

Work Phone

E-mail

Relationship to Patient

PATIENT’S DENTIST

Dentist’s Name

Dentist Work Phone

Date of Last Visit

PATIENT’S PHYSICIAN

Physician’s Name

Physician Work Phone

Date of Last Visit

GENERAL INFORMATION

What concerns you about your teeth?

Who suggested you see an orthodontist?

Why did you choose our office?

Have you had any previous orthodontic treatment?

Have any other family members been treated by deRoode Orthodontics? If yes, name

DENTAL INSURANCE INFORMATION( if apply )

Primary policy holder’s full name

Birthdate

Relationship to Patient

Insurance Company

Group #

ID#

Insurance Company Tel #

Does this policy have orthodontic benefits

Yes No Don’t know

DENTAL AND MEDICAL HISTORY (If yes, please fill in details)

Are you taking any medication?

Yes No

Do you have history of major illness?

Yes No

Have you ever taken a bisphosphonate (ie Fosamax)?

Yes No

Now or in the past, has patient had (medical):

Birth defect or hereditary problems

Yes No

Any injuries to face, neck, head

Yes No

Arthritis or joint problems

Yes No

Endocrine or thyroid problems

Yes No

Kidney problems

Yes No

Cancer, tumor, radiation or chemo

Yes No

Stomach ulcer or reflux

Yes No

Immune system problems

Yes No

Osteoporosis

Yes No

AIDS or HIV positive result

Yes No

Tuberculosis or pneumonia

Yes No

High blood pressure

Yes No

Eating disorder (anorexia, bulimia)

Yes No

Seizures, fainting spells, neurologic problems

Yes No

Heart problems, heart murmur, rheumatic heart disease

Yes No

Frequent headaches or migraines

Yes No

Tonsil or adenoid condition

Yes No

Asthma, sinus problems, hayfever

Yes No

Frequent ear infections, colds, throat infections

Yes No

Do you frequently breath through your mouth or have difficulty breathing through your nose?

Yes No

Do you snore at night?

Yes No

Smoke, chew tobacco or vape?

Yes No

Female Patients:

Are you currently pregnant or plan on becoming pregnant?

Yes No

If patient under 15, has menstruation started?

Yes No

at what age

Now or in the past, has patient had (dental):

Extra (supernumerary) or missing teeth

Yes No

Chipped or injured teeth

Yes No

Any sensitive or sore teeth

Yes No

Bleeding gums, bad taste or mouth odor

Yes No

“Gum boils”, frequent canker sores or cold sores

Yes No

Speech problems or speech therapy

Yes No

Oral habits (sucking finger/thumb, chewing pen, nails, etc)

Yes No

Abnormal swallowing (tongue thrust)

Yes No

Tooth grinding or clenching

Yes No

Clicking, locking in jaw joints

Yes No

Soreness in jaw muscles or face muscles

Yes No

Ringing in ears, difficulty chewing or opening jaw

Yes No

Diagnosed or treated for “TMJ”

Yes No

Diagnosed with gum disease

Yes No

Have you had allergies or reactions to:

Latex

Yes No

Metals

Yes No

Acrylics

Yes No

Local anesthetics (novocaine, lidocaine, xylocaine)

Yes No

Aspirin

Yes No

Ibuprofen (Motrin, Advil)

Yes No

Penicillin

Yes No

Other antibiotics or medications

Yes No

RELEASE AND WAIVER,
I authorize release of any information regarding my orthodontic treatment to my dental insurance company.

I have read the above questions and understand them. I will not hold my orthodontist or any member of her staff responsible for any erros or omissions that I have made in the completion of this form. I will notify deRoode Orthodontics of any changes in my medical or dental health.

Signer Name

Date