ARNSTINE ORTHODONTICS
MEDICAL, DENTAL HISTORY FORM FOR ADULTS

PATIENT INFORMATION

Name:            

Age Sex M F Date of Birth
Address: City: State: Zip: Tel #( )
Whom may we thank for referring you to our office?
Employed by: Occupation:  

Work Tel # ( ) Ext:

Cell Phone #( )
E-mail Address:
Your Social Security # (for accounting purposes)
Marital Status:       Single        Married         Separated        Divorced         Widowed        Remarried

Spouse’s Name:   Last: First: MI:

Date of birth:

Employed By:

Work Tel #( )

Spouse’s Social Security # (for accounting purposes)

If responsible party is other than yourself, please give information:         Not Applicable
Name: SS#: Relationship to Patient:
Address: City: State: Zip: Tel #( )

Children’s Names and Birthdates:

MEDICAL HISTORY

Your Physician’s Name:
Have you had or do you have any of the following? 
Check all that apply.
Rheumatic Fever
Heart Murmur
High Blood Pressure
Heart Attack/Stroke 
Blood Vessel Disease
Blood Disorder
AIDS/HIV Infection 		 Hepatitis
Ulcers
Herpes (Any type)
Psoriasis  
Cancer
Sinus Infection
Ear Disorder		 Diabetes 
Neck Pains 
Arthritis (Any type)
Mental Health Problems
Ear Disorder
Sleep Apnea
Migraine		 Persistent Headaches
Nerve or Brain Disease
Epilepsy
Bone Disorders
Swollen Glands
Allergies
Gastric Reflux
       
Are you allergic to Latex?

Comments
Please list any other significant information about your medical history:

YES / NO  
Yes No Are you under a physician’s care at present?     If Yes, reason:
Yes No Are you presently, or have you ever been , under the care of a psychiatrist or psychologist?
If yes, describe:
Yes No Are you currently taking any medication?     If yes, describe
Yes No Are you allergic to any medications? (Eg: aspirin, penicillin, etc.)    If yes, what?
Yes No Have you ever had any general anesthesia? | When?
   
  FEMALE PATIENT
Yes No

Do you have regular menstrual cycles?

Yes No Have you experienced menopause?
Yes No Has anyone in your family had osteoporosis?
Yes No Is there a possibility that you could be pregnant?

DENTAL HISTORY

YOUR DENTIST’S NAME: LAST VISIT

YES / NO  
Yes No Do any of your teeth hurt?  If yes,    upper right         upper left        lower right       lower left   
Yes No Have any wisdom teeth been removed?  How many? When?
Yes No Have you ever had treatment for periodontal disease (gum disease)?  If yes, describe
Yes No Have you ever had any previous orthodontic treatment (braces)?  If yes, when?
If yes, doctor’s name and address
Yes No Have there been any injuries to your mouth or teeth?  If yes, describe
Yes No Have you ever had any injury in the head and neck area?  If yes, describe
Yes No Have you ever fallen & bumped your chin, or received a blow to your jaws?  If yes, describe
Yes No Have you ever had any surgery in the head and neck area?  If yes, describe
Yes No Do you clench or grind your teeth?  If yes,   while sleeping         under stress      other
Yes No Do your jaw muscles ever feel tired?  If yes, when
Yes No Do you ever notice soreness, tightness or pain in the muscles around the jaws and face?  If yes, describe
Yes No Does it hurt to chew?  If yes, where does it hurt?
Yes No

Do you hear clicking (popping) or grating sounds in your jaw joints?  If yes, please describe:

  Right Left Since when?  During what activity?
Clicking:  
Grating

Did these joint sounds begin gradually or suddenly?   Gradually Suddenly  

   
Yes No Was there some specific event that started the joint sounds?  If yes, describe:
Yes No Have you ever experienced difficulty in opening or closing your jaws?   If yes, describe:
Yes No Have your jaws ever “locked” closed?  If yes, describe:
Yes No Have your jaws ever “locked” wide open?  If yes, describe:
Yes No Do you have pain in your jaw joint?  If yes,     right         left      Since when?
  Did your pain start    gradually or suddenly  
  During what activity? Describe nature of pain:
  What increases the pain? What decreases the pain?

Do you have any of the following habits?
Yes No Finger/Thumbsucking Yes No Gum Chewing Yes No Tongue Thrusting
Yes No Lip Biting Yes No Ice Chewing  
Yes No Nail Biting Yes No Smoking  
     

Please describe why you sought this consultation

Have you ever been treated for this problem before?  Yes No

If yes, please describe the diagnosis and treatment:
We recognize that patients sometimes have specific concerns that may not be addressed by the questions in this Clinical History Form. Please feel free to include any other information regarding your clinical history, or any other concerns that you may have, in the space below.
 

I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for a clinical examination.

Patient's Initials: | Date:7/30/2010

You will be required to sign the form during your visit to our office.

 

I hereby give permission for the use of photographs and records obtained in the process of examination, treatment and retention to be used for purposes of research, education or publication in professional journals.

Patient's Initials: | Date:7/30/2010