Adult Health History

*First Name:  
Middle Initial:
*Last Name:  
Nickname:
*Marital Status:
*Birthdate:    
Age:
*Gender:  
Email:
*Address:  
*City:  
*State:  
*Zip:  
How long at this address:
*Main Phone:  
Occupation:
Employer:
Other family members seen here:
Whom may we thank for referring you?
Spouse Information
Spouse Name:
Employer:
Occupation:
Name of Insured:
Date of Birth:
Relationship to Patient:
Name of Ins. Company:
Insurance Co. Address:
Insurance Co. Phone:
Subscriber/Policy #:
Group #:
Dentist Name:
Check-up Frequency:
Last Dental Visit:  
Have you had an orthodontic consult or treatment?
If so, when?
By whom?
Main orthodontic concern:
Please select YES or No for the Following Questions - Do Not Leave Blank
Speech problems/therapy?  
Grind or clench teeth?  
Oral habits (thumb/finger sucking, lip/nail biting)?  
Injury to face, jaw, teeth or mouth?  
Discomfort from teeth or gums?  
Pain, tenderness or noise in either jaw?  
Mouth breathing?  
Snores during sleep?  
Any missing or extra permanent teeth?  
Apprehensive about dental care?  
Requires premedication?  
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Patient Health:
List any medications you are currently taking:
Are you currently taking (or have taken in the past year) any of the following medications: Fosamax, Actonel, Boniva, Zometa, Aredia, or any other type of bisphosphonate medication to treat bone density?  
List any drug allergies or sensitivities that you have:
Latex/Metal Allergy
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect  
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure  
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Nervous Disorders  
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
Treated for Emotional Problems
Ever Been Hospitalized
Smoke or use Tobacco
Tonsils/Adenoids Removed
Is there any other condition or problem that you think we should know about?
Do you wish to receive appointment confirmations via email?
Do you wish to receive text message appointment confirmations?