ADULT Orthodontic Health History Form
Today’s Date ________________
Patient’s Last Name _______________________________ First _______________________ MI ______
DOB: ______________ Age: __________ Sex: ________ “I prefer to be called ___________________”
Home Ph. #: __________________ Cell Ph. #: ________________ Work Ph. #: _____________________
Email Address/es: ________________________________________________________________________
Best Method for Appt. Confirmations (circle): EMAIL Home Ph. Cell Ph. Work Ph. Cell Text
Patient’s Full Address: ____________________________________________________________________
List Names of Other Family Members Treated Here: ________________________________________
Person Financially Responsible for this Patient Account: ____________________________________
Do you have Insurance Coverage for Orthodontic Treatment? _____________________________
PRIMARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
SECONDARY INSURANCE
Name of Policy Holder: __________________________________ Employer: ______________________
Insurance Co. Name & Address: __________________________________________________________
SSN/ ID#: ______________________ DOB: ___________________ Group #: ________________________
Did your Dentist Recommend Orthodontic Treatment? Yes _____ or No _____
How did you hear about Family Orthodontics at KidZdent? _________________________________
Dentist Name: ____________________ Town: _______________________ Ph. #: ____________________
Date Last Seen by Dentist and Reason for Visit: _____________________________________________
Do you have any Dental Work that needs to be completed? _______________________________
Tell us a little bit about yourself…
• What do you like about your smile? ____________________________________________________
• What concerns you most about your smile? ____________________________________________
• What types of braces are you interested in? Traditional___ Clear___ Invisalign ___
• Is there a target date you expect your treatment to be completed by? __________________
• What hobbies or sports do you enjoy? __________________________________________________
Dental History Section (Answer/ Explain):
• Have you had any accidents or trauma to your teeth/ face? ____________________________
• Have you had any teeth removed? ___________ Teeth Missing? __________________________
• Any dental conditions or problems that we should be aware of? _________________________
Medical History Section (Answer Yes or No. If Yes, please explain):
Please check ALL conditions that apply to the patient:
Y N Y N Y N
Latex Allergy Heart Ailments Thyroid Disorders
ASD/ Autism Rheumatic Fever Ulcer or Colitis
Extreme Nervousness or Apprehension Epilepsy or Seizures Malignancies or Leukemia
Developmentally Delayed Heart Murmur Chicken Pox
Cerebral Palsy Sinus Ailments Mononucleosis
Hyperactivity/ ADHD Tonsilitis Hearing Ailments
Learning Disability Tuberculosis Eye Disorders
Psychiatric Care/ Emotional Ailments Kidney Ailments Physical Handicaps
Asthma or Other Respiratory Ailments Diabetes Excessive Bleeding
Liver Ailments, Jaundice or Hepatitis AIDS/ HIV + Anemia or Blood Ailments
Explanations/ Other Medical Issues:
List all medications, vitamins, supplements, or herbal medications being taken:
__________________________________________________________________________________________
Physician’s Name & Town: ________________________________________________________________
Date & Reason Last Seen by Physician: ____________________________________________________
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KidZdent follows Federal and State law by complying with HIPAA standards. Our Notice of
Privacy Practices took effect on April 15, 2003 and is available to you upon your request.
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I certify that I have read and understood the above. I understand that the information that I
have given is correct to the best of my knowledge. I will not hold KidZdent or any member of
the staff responsible for any errors or omissions I may have made in the completion of this
form. I also authorize the Doctor’s and staff of KidZdent to perform the necessary dental
services that they have explained me.
Patient Signature: ____________________________________________ Date: _____________________
