Medical Dental History Form
for Adult Patients
Closest Relative
Other dentists/dental specialists being seen currently:
Other physicians/health care providers being seen currently:
General Information
Financial Responsibility
Dental Insurance
Medical Insurance
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u)
Medical Insurance
Now or in the past, have you had:
Yes No DK/U
Birth defects or hereditary problems?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice, or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problems?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke, or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?
Have you had allergies or reactions to any of the following?
Yes No DK/U
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Other antibiotics
Ibuprofen (Motrin, Advil)
Plant pollens
Other substances
Dental History
Now or in the past, have you had:
Yes No DK/U
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste, or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
"Gum boils," frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?
Mouth breathing habit or snoring at night?
Frequent oral habits (sucking finger, chewing pen, etc)?
Teeth causing irritation to lip, cheek, or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?
Patient Health Information
List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Release and Waiver
I authorize the release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my medical or dental health.
Medical History Updates or Changes