Adult Medical History Form

Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Gender

Gender Male Female Other
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Cell Phone Number Cell Phone Number - ### - ### ####
Occupation
Employer
Spouse's Name Spouse's Name First Last
Spouse's cell phone number Spouse's cell phone number - ### - ### ####
Spouse's occupation
Spouse's employer
Do you have orthodontic coverage on your insurance?

Do you have orthodontic coverage on your insurance? Yes No I'm not sure
Name of general dentist
How did you hear about our office (check all that apply)

How did you hear about our office (check all that apply) Referral by dentist My family were treated here Google Facebook Instagram TikTok Signage Referral from a friend (please include friend's name so that we can thank them)
Name of family doctor
Do you smoke or use tobacco products?

Do you smoke or use tobacco products? Yes No
Do you have any medical conditions

Do you have any medical conditions Yes No
If yes, please list them here:
Are you taking any medications?

Are you taking any medications? No Yes (Please list them here) Yes (Please list them here)
Do you have any allergies?

Do you have any allergies? No Yes (if yes, please list them here) Yes (if yes, please list them here)

The following questions pertain to your dental and orthodontic health
	Yes	No
Have you ever experienced trauma to the teeth or jaws?	Have you ever experienced trauma to the teeth or jaws?Yes	Have you ever experienced trauma to the teeth or jaws?No
Do you have problems chewing your food?	Do you have problems chewing your food?Yes	Do you have problems chewing your food?No
Do you have problems breathing?	Do you have problems breathing?Yes	Do you have problems breathing?No
Do you suffer from sleep apnea?	Do you suffer from sleep apnea?Yes	Do you suffer from sleep apnea?No
Do you have frequent headaches or migraines?	Do you have frequent headaches or migraines?Yes	Do you have frequent headaches or migraines?No
Do you have any joint problems (arthritis)?	Do you have any joint problems (arthritis)?Yes	Do you have any joint problems (arthritis)?No
Are you taking hormones or hormone replacement threapy?	Are you taking hormones or hormone replacement threapy?Yes	Are you taking hormones or hormone replacement threapy?No
Are you on any arthritis medication?	Are you on any arthritis medication?Yes	Are you on any arthritis medication?No
Are you on any osteoporosis medication?	Are you on any osteoporosis medication?Yes	Are you on any osteoporosis medication?No
Do you go to the dentist regularly?	Do you go to the dentist regularly?Yes	Do you go to the dentist regularly?No
Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?	Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?Yes	Has your dentist told you that you need any cleanings or restorations done before orthodontic treatment?No

Date of last dental visit Date of last dental visit / MM / DD YYYY
I certify that I have answered all the questions thoroughly and completely.

I certify that I have answered all the questions thoroughly and completely. I certify that the above information is correct.
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.