Medical History Form

Medical History Form
Patient’s Name
Home/Cell Phone

Area CodePhone Number
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Patient is a minor, give parent’s or guardian’s name
Whom may we thank for referring you to our office?
General Dentist
Other family members previously in our office?
Responsible Party Information
Name
Residence (If different than patient address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long at this address?
Previous Address (if less than 3 years)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (If different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Cell Phone Carrier
Work Phone

Area CodePhone Number
Email
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
Employer
Occupation
No. Years Employed
Spouse’s Name
Relationship to Patient
Employer
Occupation
No. Years Employed
Email
example@example.com
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Orthodontic Insurance Information
Do you have insurance coverage?
Insured’s Name
Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured’s Soc. Sec. #
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group #
Contract #
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have dual coverage?
Insured’s Name
Insured's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured’s Soc. Sec. #
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Company
Group #
Contract #
Insurance Co. Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insured’s Employer
Emergency Information

By submitting the form you authorize Dr. Whitaker to release my records to other dental/medical professionals as needed during observations, treatment, and retention.
Name of nearest relative not living with you
Complete Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Medical History
Are you in good health?
Any major or unusual illnesses?
Currently being treated by a physician?
Currently taking medications?
Allergies?
Drug Sensitivity?
Latex Allergy?
Metal Allergy?
If you answered yes to any of the above, please explain:
Please check if you have any of the following:
Dental History
Have you ever had any severe head or face injuries?
History of thumb sucking or finger sucking? Stopped?
Do you play any musical (wind) instruments?
Have you consulted an orthodontist previously?
Have any family members had orthodontic treatment?
Do you normally take antibiotics prior to dental cleaning?
Previous periodontal (gum) treatment?
If you answered yes to any of the above, please explain:
When was your last dental cleaning?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please check if there is a history of:
What do you think is your orthodontic problem?
What do you hope orthodontics will accomplish?
Is there any other information that may be helpful?
Additional information:
Signature
Signature:
Date Submitted:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: