Dunn Orthodontics Adult Health History

*First Name:

Middle Initial:

*Last Name:

Nickname:

*Address:

*City:

*State:

*Zip:

How long at this address?

Previous Address (if less than 3 years)

*Home Phone:

Work Phone:

Mobile/Alt. Phone

*Gender:

Age

*Birthdate:

Marital Status

Occupation

Employer

No. Years with Current Employer

Social Security #:

Emergency Contact

Emergency Contact Phone

Preferred Office Location

Email

Spouse's Name

Date of Birth

Social Security #

Spouse's Occupation

Spouse's Employer

No. Years with Current Employer

Mobile/Alt. Phone

Work Phone

*First Name:

Middle Initial:

*Last Name:

Is there an Insurance Company that we can contact concerning orthodontic coverage?

Yes No

Insurance Company Name

Group Number

Address where claims are filed

Insured's Name

SS#

Date of Birth

Is there a second insurance company which may provide coverage?

Yes No

Insurance Company Name

Group Number

Insured's Name

SS#

Date of Birth

Dentist Name:

When was your last general dental exam?

Physician Name:

Whom may we thank for referring you?

Please check any of the folowing which you have had or presently have

Abnormal Bleeding/Hemophilia

Hay Fever

Stroke

Glaucoma

Angina Pectoris

Sinus Trouble

Blood Transfusion

Ulcers

High Blood Pressure

Allergies/Hives

Heart Disease

Excessive Bleeding

Heart Murmur

Diabetes

Bruise Easily

Pain/Noises in Jaw Joint

Rheumatic Fever

Thyroid Disease

Anemia

Emphysema

Congenital Heart Problems

Scarlet Fever

Arthritis

Chronic Cough

Artificial Heart Valve

Cancer

Artificial Joint

Tuberculosis

Heart Pacemaker

Liver Disease

Rheumatism

HIV+ or AIDS

Heart Surgery

Hepatitis A

Kidney Trouble

Venereal Disease

X-ray/Cobalt Treatment

Hepatitis B

Cortisone Medication

Cold Sores

Eplilepsy/Seizures

Yellow Skin/Jaundice

Psychiatric Treatment

Genital Herpes

Fainting/Dizzy Spells

Sickle Cell Disease

Do you have any disease or condition not listed? If so, please list:

Have you been hospitalized during the last two years?

Yes No

Have you been under a physician's care in the last two years for a specific illness?

Yes No

Have you taken any medications in the last two years?

Yes No

Please list:

Do you require medication prior to dental visits?

Yes No

Are you allergic to or made sick by any medications?

Penicillin

Aspirin

Codeine

Other:

Women: Are you pregnant?

Yes No

Have you ever been treated by a periodontist (gum specialist)?

Yes No

If so, when and by whom?

Have you ever been treated by an orthodontist?

Yes No

If so, when and by whom?

Have you ever been treated for:

Bad Bite

Problems of the Jaw

Facial Muscle Spasms

Are you aware of doing or have you been told that you do any of the following?

Clenching your Teeth

Grinding your Teeth

"Tension" Headaches

Migraine Headaches

Sore/Tired Jaw Muscles

Difficulty Opening Widely

Pain or Soreness Around your Eyes, Ears, or Other Parts of your Face

Are you presently in pain from your jaw joint or muscle?

Yes No

If you could change anything about the appearance of your teeth or face, would you do so?

Yes No

If so, what would you change?

What is your attitude toward braces?

Are you bothered by the possible look of braces on your teeth?

Yes No

Do you realize that some appointments must be scheduled during work hours?

Yes No

To the best of my knowledge, these answers are true and correct. If I ever have any change in my health, or if my medications change, I will inform the orthodontist at my next appointment.

Patient Biographical Information

Spouse Information (if applicable)

Financial Party Information

Medical and Dental History Information