Microsoft word - ocim health history adult.doc

Patient Information (please complete in ink)
Name: Mr/Mrs/Ms___________________________________________ Address: __________________________________________________________ Home Phone: _____________________ Work Phone: _____________________ Cell Phone: ____________________ Occupation: _____________________________ Employer: _____________________________________________ Who can we thank for referring you to our office? _____________________________________________ Medical History

Name of Physician: ________________________________________________________________________ Address: _________________________________________________________________________________ Are you currently being treated for any medical conditions? List:_______________________________ Are you currently taking any medications? List: _____________________________________________ Do you have any allergies? List: __________________________________________________________ Do you have any allergies to medications? If yes, describe: ____________________________________ Have you ever had any serious illnesses? If yes, describe: _____________________________________ Have you ever been hospitalized or undergone any surgeries?________________________________ For women, are you pregnant or suspect that you might be? Anticipated due date:_______________ Do you now or have you ever taken bisphosphenates (incl. Fosamax, Didronel, Boniva, Aredia, Have you had, or do you have any of the following? Yes No Please list any other significant information regarding your medical history: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Dental History What is your primary concern about your teeth and smile?_________________________________________________ Dentist: _____________________________ Address: _____________________________________________________ Yes No ___ ___ Are you currently experiencing dental pain? Have you had previous orthodontics? When?_____________________ Which Dr? ___________________ Have you ever injured your teeth or mouth? Describe: __________________________________________ Do you have, or have you, experienced soreness/tightness/pain in jaw muscles? Do you have, or have you, experienced clicking/popping/grinding in your jaw joints? Do you have, or have you, experienced difficulty opening or closing your jaw? Do you have missing or extra permanent teeth?
How often do you brush and floss each day? Brush _____ times per day Floss _____ times per day
Dental Insurance Information

Primary Insurance Company: _______________________________________________________________________ Address: ____________________________________________ Group/Plan Number: __________________________ Policy holder name: __________________________________ Secondary Insurance Company: _____________________________________________________________________ Address: ____________________________________________ Group/Plan Number: __________________________ Policy holder name: __________________________________
I acknowledge that I read and understand the above medical and dental information and certify the above
information is correct. If there are any changes to the above information, I will notify the office of any changes
that occur. I also give my permission for Dr. Wong and his team to perform an initial orthodontic evaluation.
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_____________________ _______________ ____________________________
Signature
Dr. Lyndon Wong

Source: http://ocmilton.com/Portals/0/forms/OCiM_Health_History_Adult.pdf