American Association of Orthodontists MEDICAL DENTAL HISTORY FORM – ADULT
Patient's Last Name: ___________________________
First Name: _____________________________
I Prefer To Be Called: _______________________
S.S.N./S.I.N.: _______________ Home Phone No.: (
E-mail address: ___________________________________________
Cell phone number: ____________________ Pager number:____________________
Patient's Address: _____________________________________________________________________________
If less than 5 years at current address, previous address:___________________________________________________________________________________
Employer:________________________________
Name Of Spouse/Closest Relative: ________________________________
Relationship To You: __________________________
Address (if different than yours): _____________________________________________________________________________
Name Of Patient's Dentist: ___________________________________
Dentist's Address: ____________________________________________________________________________________
Reason: _________________________________________________
Name Of Patient's Physician(s): _________________________________________
Physician's Address: _______________________________________________________________________
Reason: __________________________________________
Who suggested that you might need orthodontic treatment? _____________________________
Why did you select our office? ____________________________________________________
Who Is Financially Responsible For This Account?
Last Name: ________________________________
Address (if different than patient’s)______________________________________________________________________
City: ______________________________________
Insurance Coverage For Dental Treatment? Yes
Insurance Coverage For Orthodontic Treatment? Yes
Primary Policy Holder's Name: _____________________________________________-_______________
Employed By: __________________________________________________________
Dental Insurance Company: _________________________________________________________
Secondary Policy Holder's Name: __________________________________________ S.S.N./S.I.N.: _______________________________
Employed By: __________________________________________________________
Dental Insurance Company: _____________________________________________
Medical Insurance Company: ______________________________
or the following questions mark yes, no, or don't know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation. MEDICAL HISTORY Now or in the past, have you had: dk/u Are you currently taking or have you ever taken any
intravenous bisphosphonates for serious bone
dk/u Birth defects or hereditary problems?
disorders/cancers: such as Zometa (zolendronic acid), Aredia
dk/u Bone fractures, any major accidents? dk/u Rheumatoid or arthritic conditions? dk/u Are you currently taking or have you ever taken any oral dk/u Endocrine or thyroid problems?
bisphosphonates for osteoporosis, osteopenia or other uses: such as Fosamax (alendronate), Actonel (risendronate),
dk/u Kidney problems?
Boniva (ibandronate) Skelid (tiludronate), Didronel
dk/u Diabetes? dk/u Cancer, tumor, radiation treatment or chemotherapy? dk/u Are you taking medication, nutrient supplements, herbal dk/u Stomach ulcer or hyperacidity?
medications or non prescription medicine? Please name them.
dk/u Polio, mononucleosis, tuberculosis, pneumonia? dk/u Problems of the immune system? dk/u AIDS or HIV positive? dk/u Hepatitis, jaundice or liver problem? dk/u Fainting spells, seizures, epilepsy or neurological problem? dk/u Mental health disturbance or depression? dk/u Vision, hearing, tasting or speech difficulties? dk/u Loss of weight recently, poor appetite? dk/u History of eating disorder (anorexia, bulimia)? dk/u Excessive bleeding or bruising tendency, anemia or dk/u Do you currently have or ever had a substance abuse dk/u High or low blood pressure? dk/u Do you chew or smoke tobacco? dk/ u Tired easily? dk/u Operations? Describe: _______________________ dk/u Chest pain, shortness of breath or swelling ankles? dk/u Hospitalized? For: __________________________ dk/u Cardiovascular problem (heart trouble, heart attack, angina, dk/u Other physical problems or symptoms? Describe: _______
coronary insufficiency, arteriosclerosis, stroke, inborn heart
defects, heart murmur or rheumatic heart disease)?
dk/ u Being treated by another health care professional? dk/u Skin disorder?
Date of most recent physical exam? __________________
dk/u Do you have a well-balanced diet? Do you have any other medical conditions that we should know about? dk/u Frequent headaches, colds or sore throats?
________________________________________________________
dk/u Eye, ear, nose or throat condition? dk/u Hayfever, asthma, sinus trouble or hives? WOMEN ONLY dk/u Tonsil or adenoid conditions? dk/u Osteoporosis? dk/u Are you pregnant? dk/u Are you anticipating becoming pregnant? Allergies or reactions to any of the following: dk/u Local anesthetics (Novocaine or Lidocaine) FAMILY MEDICAL HISTORY dk/u Aspirin
Do your parents or siblings have, or have ever had any of the following
dk/u Ibuprofen (Motrin, Advil) dk/u Penicillin or other antibiotics
Bleeding disorders________________________________________________
dk/u Sulfa drugs
Diabetes________________________________________________________
dk/u Codeine or other narcotics
Arthritis________________________________________________________
dk/u Metals (jewelry, clothing snaps)
Severe allergies__________________________________________________
dk/u Latex (gloves, balloons)
Unusual dental problems___________________________________________
dk/u Vinyl
Jaw size imbalance________________________________________________
dk/u Acrylic
Any other family medical conditions that we should know about? ___________
dk/u Animals dk/u Foods (specify) ___________________________________ dk/u Other substances (specify) __________________________ DENTAL HISTORY dk/u Any pain or soreness in the muscles of the face or around Now or in the past, has the patient had: dk/u Permanent or "extra" (supernumerary) teeth removed? dk/u Difficulty in chewing or jaw opening? dk/u Supernumerary (extra) or congenitally missing teeth? dk/u Have you ever been treated for "TMD" or "TMJ" problems? dk/u Chipped or otherwise injured primary (baby) or permanent dk/u Aware of loose, broken or missing restorations (fillings)? dk/u Any teeth irritating cheek, lip, tongue or palate? dk/u Teeth sensitive to hot or cold; teeth throb or ache? dk/u Concerned about spaced, crooked or protruding teeth? dk/u Jaw fractures, cysts or mouth infections? dk/u Aware or concerned about under or over developed jaw? dk/u "Dead teeth" or root canals treated? dk/u Any relative with similar tooth or jaw relationships? dk/u Bleeding gums, bad taste or mouth odor? dk/u Any wisdom tooth problems? dk/u Periodontal "gum problems"? dk/u Had periodontal (gum) treatment? dk/u Food impaction between teeth? dk/u Had any serious trouble associated with any previous dental dk/u "Gum boils", frequent canker sores or cold sores? dk/u Thumb, finger, or sucking habit? Until what age ________? dk/u Been under another dentist's care?
Specialist _______________________________
dk/u Abnormal swallowing habit (tongue thrusting)?
Other __________________________________
dk/u History of speech problems? dk/u Ever had a prior orthodontic examination or treatment? dk/u Mouth breathing habit, snoring or difficulty in breathing? dk/u Would you object to wearing orthodontic appliances dk/u Tooth grinding or jaw clenching? dk/u Any pain, clicking or locking in jaw or ringing in the ears? How often do you brush:
What is your primary concern? Why are you here? __________________________________________________________________
Questions: ___________________________________________________________________________________________________________________________
DOCTOR CONTACT INFORMATION
Doctor's Last Name: _____________________________
E-mail address: ____________________________________________
Doctor's Address: _____________________________________________________________________________
City: _______________________________________
I have read and understand the above questions. I will not hold my orthodontist or any member of his/her 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. Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed: ______________________________________________________ Date Signed _________________ (Dental staff member)
MEDICAL HISTORY UPDATE OR CHANGES
Comments: _______________________________________________________________________________ Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member)
MEDICAL HISTORY UPDATE OR CHANGES
Comments: ______________________________________________________________________________
Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: ______________________________________________________________________________
Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: _______________________________________________________________________________ Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member)
American Association of Orthodontists 2003
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American Association of Orthodontists