Smith + Heymann Ortho Adult Medical/Dental History Form

Adult Medical/Dental History Form
Patient's Name

First NameLast Name
Name of Person/Persons Completing Form
Prefers to be addressed as
Gender
Age
Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Email
example@example.com
Preferred way to receive reminders:
Patient's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who may we thank for referring you?
What helped you decide to contact Smith & Heymann Orthodontics?
Marital Status
Do you have children? If yes, please list their names and ages below.
Contact in case of Emergency (Name)

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell
Please enter a valid phone number.Format: (000) 000-0000.
Dental Insurance

In order to verify ortho coverage and retrieve benefits, we must have member ID or social if no member id was provided.
Do you have Dental Insurance?
If yes, please provide details below.
Policy Holder's Name

First NameLast Name
Primary Insurance Co
Please provide state if Delta Dental is provider
Policy Holder's Employer
SSN/Member ID
SSN/Member ID
Do You Have Ortho Coverage?
Group #
Policy Holder’s Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insured's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insurance
Do you have secondary insurance?
If yes, please provide secondary insurance details below.
Policy Holder's Employer
Policy Holder's Name

First NameLast Name
Secondary Insurance Co
SSN/Member ID
SSN
Do You Have Ortho Coverage?
Group #
Policy Holder's Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dental History
Do you have a Dentist? If yes, please provide details below.
Patient's Dentist Name
Date of Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have there been any injuries to the face, mouth or teeth?
Have you had or do you presently have any of the following habits?
Have you been informed of any missing or extra permanent teeth?
Are you aware of sores, lumps or irritated areas in the mouth?
Has an orthodontist been consulted previously? If yes, please provide details below.
Orthodontist's Name
Date of Last Orthodontic Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you ever been treated for
Are you frightened or anxious about Orthodontic treatment?
Are you concerned about the appearance of your teeth?
Do you have any speech problems?
Is there anything you would like to change about your smile?
What aspect of dental treatment are you most concerned with?
Reason for consultation (chief concern)
Has there ever been any orthodontic treatment for any other member of your family? If yes, please provide the patient(s) names, their doctor's name, and if the patient was satisfied with treatment.
Medical History
Is your general health good at this time?
Comments
Are you under the care of a physician at this time?
If yes, please provide details
What is the name of your family physician?
Date of last physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you taking any medication?
If yes, please list below.
Are you allergic to any medication?
If yes, please list the names of medications you are allergic to
Have you ever taken any diet medication (Fen-Phen)?
Have you ever had a serious illness or been hospitalized?
Have you ever had a serious illness or been hospitalized? If yes, please explain.
Have you had your tonsils and/or adenoids removed?
If yes, what age?
Do you have any special conditions not listed? If yes, please explain
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?
If yes, please provide antibiotic name and method.
Do you use tobacco? (smoking or chewing)
What is your approximate height?
What is your approximate weight?
Do you have now, or have you ever had any of the following?
Please check if YES or leave unchecked for NO:
Please check if YES or leave unchecked for NO:
Please check if YES or leave unchecked for NO:
HIPAA Consent
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address. I have read the HIPAA Policy and agree to the terms.
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.
Signature
Should be Empty:

Adult Medical/Dental History Form

Dental Insurance

If yes, please provide details below.

Secondary Insurance

If yes, please provide secondary insurance details below.

Dental History

Medical History

Do you have now, or have you ever had any of the following?

HIPAA Consent