Confidential medical dental history form

CONFIDENTIAL
MEDICAL DENTAL HISTORY FORM

Date

Month

Day

Year

PATIENT INFORMATION

Patient’s Last Name*

First Name*

Middle Initial

Date of Birth*

Month

Day

Year

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

Month

Day

Year

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

Month

Day

Year

PATIENT’S PHYSICIAN

Physician’s Name

Physician Work Phone

Date of Last Visit

Month

Day

Year

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

Month

Day

Year

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.

Date

Month

Day

Year

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