Medical History Form

Medical History Form

Patient Information

Gender


Primary Phone Number



Dental History


How did the patient hear about our Practice?

Has the patient visited an orthodontist before?


Has patient's tonsils or adenoids been removed?
Has patient ever experienced jaw joint pain/discomfort (TMJ/TMD)?
Does patient have any missing or extra permanent teeth?
Has patient ever had an injury to (select all that apply):
Does patient have speech problems?
Does patient smoke?
Has patient had any of the following habits?

Medical History


Do you have any allergies/sensitivities to medications or latex?
Are you currently taking any prescription or over-the-counter medications?
Have you had any serious illnesses or operations? If yes, describe:
Have you ever had a blood transfusion?
(Women)
Check if you have or have ever had any of the following:

Insurance Information
















Authorization

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.




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