Adult Medical History Dummy | Scantlebury Orthodontics

Patient Information

First Name

Gender

Last Name

Home Address

E-mail Address

State

State / Province / Region

Home Phone #

City

Mobile Phone #

ZIP

ZIP / Postal Code

Work Phone #

Dentist's Full Name

First

Birth Date

Referred By

First

Age

Family Members Seen By Us

First

Spouse Information

First Name

E-mail Address

Last Name

Home Phone #

Birth Date

Work Phone #

Age

Cell Phone #

Patient's Medical History

Are you in good health?

Yes
No

Any major illness?

Yes
No

Have you been under the care of a physician for any illness in the last 12 months?

Yes
No

Please select “Yes” to any illness or disability for which the patient is undergoing treatment:

Diabetes

Yes
No

Anemia

Yes
No

Epilepsy

Yes
No

Nervous Disorders

Yes
No

Asthma

Yes
No

Endocrine Problems

Yes
No

Tuberculosis

Yes
No

Heart Trouble

Yes
No

Prolonged Bleeding

Yes
No

Rheumatic Fever

Yes
No

Fainting/Dizziness

Yes
No

Bone Disorders

Yes
No

Any other illness we should be aware of

Do you have tendency to:

Colds

Yes
No

Sore Throats

Yes
No

Ear Infections

Yes
No

Have tonsils and adenoids been removed?

Yes
No

At What Age?

List any drugs/medications now being taken, and give reason

List any allergies or drug sensitivities

For Women: Are you using a prescribed method of birth control?

Yes
No

Are you pregnant?

Yes
No

Are you nursing?

Yes
No

Patient's Dental History

Have you ever had or been evaluated for orthodontic treatment?

Yes
No

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes
No

Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ/TMD)?

Yes
No

Your current dental health is

Good
Fair
Poor

Do you like your smile?

Yes
No

Gums ever bleed?

Yes
No

Have you ever had an injury to your:

Mouth
Teeth
Chin

Do you have any speech problems?

Do you generally breathe through your mouth?

Yes
No

If yes, please choose:

While Awake?
While Asleep?

Do you have any missing or extra permanent teeth?

Yes
No

Orthodontic Insurance

Primary

Orthodontic Coverage?

Yes
No

Dental Coverage?

Yes
No

Insurance Co. Name

First

Insurance Co. Address

Street Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Insured’s name

First

Relation

Insured‘s Birthday

Insured’s ID#

Insured’s SS#

Insured’s Employer

Secondary

Orthodontic Coverage?

Yes
No

Dental Coverage?

Yes
No

Insurance Co. Name

First

Insurance Co. Address

Street Address

Insurance Co. Phone #

Group # (Plan, Local or Policy #)

Insured’s name

First

Relation

Insured‘s Birthday

Insured’s ID#

Insured’s SS#

Insured’s Employer