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Microsoft word - health history form

MARLBORO ORTHODONTICS HEALTH HISTORY FORM Patient Name____________________________________________________ Birthdate____________ Last First Middle Initial Name you like to be called________________ Home Phone_________________ Sex □ Male □ Female Address____________________________________________________________________________ Street City State Zip Who may we thank for referring you to our office? ___________________________________________ Now or in the past, has the patient had: (Check DK if you Don’t Know the answer to the question) Yes No DK □ □ □ Birth defects or hereditary problems? □ □ □ Other substances ________________________ □ □ □ Bone fractures or major injuries? Now or in the past, has the patient had: □ □ □ Arthritis or joint problems? □ □ □ Hepatitis, jaundice, or other liver problems? □ □ □ Erupting teeth very early or very late? □ □ □ Seizures, fainting, neurologic problems? □ □ □ Baby teeth removed that were not loose? □ □ □ Mental health disorder or depression? □ □ □ Permanent or extra (supernumerary) teeth removed? □ □ □ Frequent headaches or migraines? □ □ □ Supernumerary (extra) or congenitally missing teeth? □ □ □ Excessive bleeding or bruising, anemia? □ □ □ Chipped or injured primary or permanent teeth? □ □ □ Chest pain, shortness of breath, tire easily, □ □ □ Any sensitive or sore teeth? □ □ □ Any lost or broken fillings? □ □ □ Heart defect or murmur, rheumatic heart disease? □ □ □ Jaw fractures, cysts, infections? □ □ □ Vision, hearing, or speech problems? □ □ □ Any teeth treated with root canals or pulpotomies? □ □ □ Frequent ear or throat infections, colds? □ □ □ Frequent canker sores or cold sores? □ □ □ Asthma, sinus problems, hayfever? □ □ □ History of speech problems or speech therapy? □ □ □ Tonsil or adenoid condition? □ □ □ Difficulty breathing through nose? □ □ □ Does the patient frequently breathe through □ □ □ Mouth breathing habit or snoring at night? □ □ □ Frequent oral habits (sucking finger, chewing pen, etc)? □ □ □ Has the patient ever taken intravenous □ □ □ Teeth causing irritation to lip, check or gums? bisphosphonates such as Zometa, Aredia or Didronel for bone disorder or cancer? □ □ □ Tooth grinding or clenching? □ □ □ Has the patient ever taken oral bisphosphonates □ □ □ Clicking, locking in jaw joints? such as Fosamax, Actonel, Boniva, Skelid or □ □ □ Soreness in jaw muscles or face muscles? □ □ □ Been treated for TMJ or TMD problems? Has the patient had allergies/reactions to the following? □ □ □ Any broken or missing fillings? □ □ □ Any serious trouble associates with previous □ □ □ Local anesthetics (novocaine, lidocaine) □ □ □ Has your child ever been diagnosed with gum Any other medical/dental information you’d like to share: □ □ □ Metals (jewelry, clothing snaps) ________________________________________________ ________________________________________________ □ □ □ Other antibiotics _________________________ □ □ □ Acrylics Name_____________________________________________________Marital Status_________ Last First Middle Residence______________________________________________________________________ Street City State Zip Mailing Address_________________________________________________________________ Street City State Zip How long at this address ___________Home Phone______________Work Phone_____________ Previous Address (If less than 3 yrs.)_________________________________________________ Social Security # _______________Birthdate____________Relationship to Patient ____________ Employer______________________Occupation_______________No. Years Employed________ E-Mail Address (Will not be sold or shared with any other party) ________________________________________
Spouse’s Name___________________________________Relationship to Patient____________
Employer______________________Occupation_______________No. Years Employed________ Social Security # _______________Birthdate_____________Work Phone_______ ____________ Policy Holder’s Name ________________________________ Subscriber ID #________________ Insurance Company ____________________________________Group #___________________ Insurance Co. Address ___________________________Insurance Co. Phone_______________ Policy Holder’s Employer __________________________________________________________ Policy Holder’s Name ________________________________ Subscriber ID #________________ Insurance Company ____________________________________Group #___________________ Insurance Co. Address ___________________________Insurance Co. Phone_______________ Policy Holder’s Employer __________________________________________________________ Patient’s General Dentist_______________________________Phone #_____________________ Other Dental Professionals Seen:___________________________________________________ Note: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my orthodontist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health. I understand that where appropriate, credit bureau reports may be obtained. Signature (Parent/Guardian if patient is a minor) __________________________________________ Date: ______________

Source: http://www.marlboro-braces.com/Portals/0/Health_History_Form.pdf

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