Campbell Ortho

Adult History Form

We would like to welcome you to our office. In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation.

Patient Information

Name:

SSN:

Drivers License:

Birthdate:

Current Address:

City:

State:

Zip Code:

Previous Address:

City:

State:

Zip Code:

Home Phone:

Mobile or Pager:

Work Phone:

Ext:

Employer:

Occupation:

How long at current job:

Spouse Information

Name:

SSN:

Drivers License:

Birthdate:

Employer:

Occupation:

How long at current job:

Work Phone : Ext:

General Information

Related patients that are/have been in our care:

Names and Ages of any children:

Who may we thank for referring you to our office?:

What is your chief orthodontic concern?:

Insurance Information

Primary Insurance

Primary Insurance Co. Name:

Address:

City:

State:

Zip Code:

Phone:

Group:

Policyholders name:

Birthdate:

SSN:

Employer:

Relation to patient:

Secondary Insurance

Secondary Insurance Co. Name:

Address:

City:

State:

Zip Code:

Phone:

Group:

Policyholders name:

Birthdate:

SSN:

Employer:

Relation to patient:

Emergency Contact Information

Who Should we contact in the event of an emergency ?: Relation:

Home phone:

Work phone:

Mobile phone:

Dental History

General Dentist: Date of last visit:

Do you like your smile

No Yes

Do you floss your teeth daily?

No Yes

Have you ever had a serious problem with any prior dental work

No Yes

Do you have any missing or extra permanent teeth?

No Yes

Have there been any:

Have there been any injuries to the face, mouth, teeth, or chin?

No Yes

Jaw joint pain

Yes No

Popping/Clicking jaw joints?

No Yes

Tightness in jaw joints?

Yes No

Jaws tired during meals

No Yes

Severe/Frequent headaches

Yes No

Medical History

Physician: Phone:

Please list all medications you are taking:

Allergies

Are you allergic to any of the following :

Aspirin

Yes No

Any metal such as Nickel

No Yes

Codeine

Yes No

Dental anesthetics

Yes No

Erythromycin

Yes No

Latex

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Any Plastics

Yes No

Please list any other medications to which you are allergic:

History Continued

Do any of the following apply to you? :

Anemia or Radiation treatment

Yes No

Artificial Bones or Joints

Yes No

Artificial Valves

Yes No

Arthritis

Yes No

Asthma

Yes No

Bleeding disorder

Yes No

Blood transfusing

Yes No

Cancer/Chemotherapy

Yes No

Congenital heart defect

Yes No

Diabetes

Yes No

Difficulty breathing

Yes No

Drug or Alcohol abuse

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Fever Blisters or Herpes?

Yes No

Glaucoma

Yes No

Handicap or Disability

Yes No

Heart attack or stroke

Yes No

Heart murmur

Yes No

Heart Surgery or Pacemaker

Yes No

Hemophilia

Yes No

Hepatitis

Yes No

High or Low blood pressure

Yes No

HIV or AIDS

Yes No

Hospitalization

Yes No

Kidney or Liver problems

Yes No

Mitral valve prolapse

Yes No

Psychiatric or Mental problems

Yes No

Rheumatic or Scarlet fever

Yes No

Shingles

Yes No

Sinus problems

Yes No

Tuberculosis

Yes No

Please explain any serious medical condition that you have ever had:

Please Read and Sign Below

The information that I have provided is correct to the best of my knowledge. I understand that it is my responsibility to inform this practice of any changes in my medical status. I also understand that this practice reserves the right to verify the credit status (obtain a report) of any potential responsible party.

Signature: Date:

Verification

Please click on the human verification checkbox before submitting your form.