Patient Form – Adult - Havener Orthodontics

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If you have any questions, please contact our offices at 956-381-8262

Medical Dental History Form Adult Patients

Patient

Patient Name

First

Middle

Last

Title

Mr.
Mrs.
Ms.
Miss.
Dr.
Other

I prefer to be called:

Title (other)

Birth Date

Age

Sex

Male
Female

Social Security Number

Marital Status

Single
Married
Separated
Divorced
Widowed

Home Address

City, State, Zip

Home Phone

Cell Phone

Occupation

Employer

Work Phone

Closest Relative

Spouse or closest relative name

Spouse or relative title

Mr.
Mrs.
Ms.
Miss.
Dr.
Other

Relationship to patient

Other (spouse or relative title)

Spouse or relative's address (if different)

Spouse or relative's cell phone

Spouse or relative's home phone (if different)

Spouse or relative's work phone

Dentist

Patient's Dentist

Address, City, State

Date Last Seen

Reason

Next Appointment Date

General Information

What concerns you about your teeth?

Who suggested that you might need orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment or consultations:

Have any other family members been treated in this office? Please name them:

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

Financial Responsibility

Who is financially responsible for this account?

Home Address

City, State, Zip

Home Phone

Cell Phone

Social Security Number

Employer

Dental Insurance

Do you have dental insurance?

Primary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address

Phone Number

Employer

Insurance company

Group #

ID #

Do you have dual coverage

Secondary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (if different)

Phone Number (if different)

Employer

Does this policy have orthodontic benefits?

Yes
No
Don't Know

Physician

Patient's Physician

Physician's Phone

Patient Health Information

Do you take antibiotic pre-medication before any dental procedures?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Have you ever taken any medications to strengthen your bones? Please describe:

Have you noticed any unusual changes in your face or jaws?

Any other physical problems?

Please explain

How often do you brush?

How often do you floss?

Are you pregnant?

Are you trying to become pregnant?

Medical History

Now or in the past, have you had: (Check all that apply)

Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
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 problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, 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?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Do you frequently breathe through his/her mouth?
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Have you had allergies or reactions to any of the following? (check all that apply)

Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances

Other substances (please explain)

Dental History

Now or in the past, have you had: (check all that apply)

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Have you 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?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?

Please review your answers before submitting the form.

Comment

Please Fill Out Our Form

If you have any questions, please contact our offices at 956-381-8262

Medical Dental History Form Adult Patients

Patient

Patient Name

First

Middle

Last

Title

Mr.
Mrs.
Ms.
Miss.
Dr.
Other

I prefer to be called:

Title (other)

Birth Date

Age

Sex

Male
Female

Social Security Number

Marital Status

Single
Married
Separated
Divorced
Widowed

Home Address

City, State, Zip

Home Phone

Cell Phone

Occupation

Employer

Work Phone

Closest Relative

Spouse or closest relative name

Spouse or relative title

Mr.
Mrs.
Ms.
Miss.
Dr.
Other

Relationship to patient

Other (spouse or relative title)

Spouse or relative's address (if different)

Spouse or relative's cell phone

Spouse or relative's home phone (if different)

Spouse or relative's work phone

Dentist

Patient's Dentist

Address, City, State

Date Last Seen

Reason

Next Appointment Date

General Information

What concerns you about your teeth?

Who suggested that you might need orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment or consultations:

Have any other family members been treated in this office? Please name them:

Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain.

Financial Responsibility

Who is financially responsible for this account?

Home Address

City, State, Zip

Home Phone

Cell Phone

Social Security Number

Employer

Dental Insurance

Do you have dental insurance?

Primary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address

Phone Number

Employer

Insurance company

Group #

ID #

Do you have dual coverage

Secondary policy holder’s full name

Social Security Number

Relationship to patient

Date of Birth

Address (if different)

Phone Number (if different)

Employer

Does this policy have orthodontic benefits?

Yes
No
Don't Know

Physician

Patient's Physician

Physician's Phone

Patient Health Information

Do you take antibiotic pre-medication before any dental procedures?

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Have you ever taken any medications to strengthen your bones? Please describe:

Have you noticed any unusual changes in your face or jaws?

Any other physical problems?

Please explain

How often do you brush?

How often do you floss?

Are you pregnant?

Are you trying to become pregnant?

Medical History

Now or in the past, have you had: (Check all that apply)

Emotional, sensory or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
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 problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, 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?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoids removed?
Do you frequently breathe through his/her mouth?
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Have you had allergies or reactions to any of the following? (check all that apply)

Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances

Other substances (please explain)

Dental History

Now or in the past, have you had: (check all that apply)

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Have you 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?
Frequent habit of thumb/finger sucking?
Frequent habit of tongue thrust?
Frequent habit of fingernail biting?
Frequent habit of lip sucking?

Please review your answers before submitting the form.