Medical/Dental History Form

* Patient's Last Name:
* First Name:
* Middle Initial:
* Birthdate:
Home Phone:
Mobile Phone:
Marital Status:
* Home Address:
* City:
* State:
* Postal Code:

Name of spouse/closest relative:
Phone Number:
His/Her Address:
*Postal Code:

Patient's Dentist

Practice Name:

Patient's General Medical Practitioner

Practice Name:

General Info

Your Occupation:
Business Phone:
Work Email Address:
Home Email Address:
Insurance Coverage:
In case we cannot reach you, person to contact:

Present Weight:
Present Height:
Favorite sports, hobbies, and avocations:
Birth defects or hereditary problems?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?
Does the patient currently have or ever had a substance abuse problem?
Operations (Surgical Procedures)?
If yes, hospitalized for:
Being treated by another health care professional?
If yes, being treated for:
Other physical problems or symptoms?
Date of the most recent physical exam:

Female Patient

Are you pregnant?
Are you taking birth control pills?
Are you anticipating becoming pregnant?

Now or in the past, have you had:

Permanent or extra teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any broken or missing fillings?
Jaw fractures, cysts, infections
Any teeth treated with root canals or pupotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Frequent oral habits (sucking finger, chewing gum, etc.)
Teeth causing irritation to lip, cheek, or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Have you been treated for "TMJ" or "TMD" problems?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Date of last dental examination:
How often do you brush?
How often do you floss?
What is the primary concern - why are you here?
Realizing that successful treatment greatly depends upon the patient's complete co-operation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?
I have read and understand the above questions. I will not hold my orthodontist or any member of the staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.