Work - Viva Smiles | Family & Kids Orthodontist

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Adult Medical History Form

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain optimal oral health. Please fill out this form completely. The better we communicate, the better we can care for you!

ABOUT YOU

Today’s Date:

Date

Email Address:

example@example.com

Name:

Prefix

Name

First Name Middle Name Last Name

I prefer to be called

Gender:

Male

Female

Birthdate:

Date

Age:

SS#:

Home Address:

Street Address City State / Province / Region ZIP / Postal Code

Marital Status

Single

Married

Partnered

Divorced/Separated

Widowed

Home #:

Please enter a valid phone number.

Cell/Other #:

Please enter a valid phone number.

Work #:

Please enter a valid phone number.

Ext:

Drv Lic #:

Employer:

Employer’s Address:

Street Address City State / Province / Region ZIP / Postal Code

How long there?

Occupation:

When is the best time to reach you?

Whom may we thank for referring you?

Other family members seen by us:

Previous/Present Dentist:

Person Responsible for Account:

SPOUSE INFORMATION

His / Her Name:

Employer:

Work #:

Please enter a valid phone number.

Ext:

Drv Lic #:

Birthdate:

Date

Age:

SS#:

Relative or Friend not living with you (for emergency).

His / Her Name:

Work #:

Please enter a valid phone number.

Home #:

Please enter a valid phone number.

ORTHODONTIC INSURANCE

Primary Insurance

Orthodontic Coverage?

Yes

Dental Coverage?

Yes

Insurance Co. Name:

Insurance Co. Address:

Street Address City State / Province / Region ZIP / Postal Code

Insurance Co. Phone #:

Please enter a valid phone number.

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthdate:

Date

Insured’s SS#:

Insured’s Employer:

Employer’s Address:

Street Address City State / Province / Region ZIP / Postal Code

Secondary Insurance

Orthodontic Coverage?

Yes

Dental Coverage?

Yes

Insurance Co. Name:

Insurance Co. Address:

Street Address City State / Province / Region ZIP / Postal Code

Insurance Co. Phone #:

Please enter a valid phone number.

Group # (Plan, Local or Policy #):

Insured’s Name:

Relation:

Insured’s Birthdate:

Date

Insured’s SS#:

Insured’s Employer:

Employer’s Address:

Street Address City State / Province / Region ZIP / Postal Code

Payment is due in full at the end of treatment.

Unless prior arrangements have been approved. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office. I understand that I am responsible for all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered, to my insurance company.

Signature

Date

MEDICAL HISTORY

Do you have a personal physician?*

Yes

Physician’s Name:

Phone #:

Please enter a valid phone number.

Date of last visit:

Date

Your current physical health is:*(Required)

Good

Fair

Poor

Are you currently under the care of a physician?*(Required)

Yes

Do you smoke or use tobacco in any other form?*(Required)

Yes

Have you had any metal rods, pins or implants?*(Required)

Yes

Are you taking any prescription / over-the-counterdrugs?*(Required)

Yes

Have you ever taken Phen-Fen? (Also known as Redux or Pondimin)*(Required)

Yes

Have you ever taken Fosamax, or any other bisphosphonate?*(Required)

Yes

For Women:

Are you using a prescribed method of birth control?

Yes

Are you pregnant?

Yes

Are you nursing?

Yes

Have you ever had any of the following diseases or medical problems?:

Abnormal Bleeding/Hemophilia*(Required)

Yes

AIDS*(Required)

Yes

Alcohol/Drug Abuse*(Required)

Yes

Anemia*(Required)

Yes

Arthritis*(Required)

Yes

Artificial Bones/Joints/Valves*(Required)

Yes

Asthma*(Required)

Yes

Blood Transfusion*(Required)

Yes

Cancer/Chemotherapy*(Required)

Yes

Colitis*(Required)

Yes

Congenial Heart Defect*(Required)

Yes

Diabetes*(Required)

Yes

Difficulty Breathing*(Required)

Yes

Emphysema*(Required)

Yes

Epilepsy*(Required)

Yes

Fainting Spells*(Required)

Yes

Frequent Headaches*(Required)

Yes

Glaucoma*(Required)

Yes

Hay Fever*(Required)

Yes

Heart Attack/Surgery*(Required)

Yes

Heart Murmur*(Required)

Yes

Hepatitis*(Required)

Yes

Herpes/Fever Blisters*(Required)

Yes

High Blood Pressure*(Required)

Yes

HIV*(Required)

Yes

Hospitalized for Any Reason*(Required)

Yes

Kidney Problems*(Required)

Yes

Liver Disease*(Required)

Yes

Low Blood Pressure*(Required)

Yes

Lupus*(Required)

Yes

Mitral Valves Prolapse*(Required)

Yes

Pacemaker*(Required)

Yes

Psychiatric Problems*(Required)

Yes

Radiation Treatment*(Required)

Yes

Rheumatic/Scarlet Fever*(Required)

Yes

Seizures*(Required)

Yes

Shingles*(Required)

Yes

Sickle Cell Disease/Traits*(Required)

Yes

Sinus Problems*(Required)

Yes

Stroke*(Required)

Yes

Thyroid Problems*(Required)

Yes

Tuberculosis (TB)*(Required)

Yes

Ulcers*(Required)

Yes

Venereal Disease*(Required)

Yes

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?*

Aspirin

Yes

Codeine

Yes

Dental Anesthetics

Yes

Erythromycin

Yes

Jewelry/Metals

Yes

Latex

Yes

Penicillin

Yes

Tetracycline

Yes

Other

DENTAL HISTORY

What are your main concerns that you would like orthodontics to accomplish?*(Required)

Have you ever had or been evaluated for orthodontic treatment?*(Required)

Yes

Have you ever had a serious/difficult problem associated with any previous dental work?*(Required)

Yes

Do you now or have you ever experienced pain/ discomfort in your jaw joint(TMJ/TMD)?*(Required)

Yes

Your current dental health is:*(Required)

Good

Fair

Poor

Do you still have wisdom teeth?*(Required)

Yes

Have you ever had an injury to your:*(Required)

Mouth

Teeth

Chin

None

Do you have any speech problems?*(Required)

Yes

Do you generally breathe through your mouth?*(Required)

Yes

Do you have any missing or extra permanent teeth?*(Required)

Yes

Are you happy with the way your smile looks?*(Required)

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. This office reserves that right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

Signature(Required)

Date:*(Required)

Date

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.