Mviewortho.com

MEDICAL & DENTAL HISTORY FORM
PATIENT INFORMATION
Patient’s Last Name:
First Name:
FAMILY INFORMATION (IF PATIENT IS A MINOR)
Responsible Party:
Relationship to Patient (eg Mom, Stepmom, Guardian, Other): Marital Status: ( ) Married ( ) Single ( ) Separated ( ) Divorced ( ) Widowed Spouse’s Name:
Spouse’s Relationship to Patient: ( ) Mom ( ) Dad ( ) Stepmom ( ) Stepdad ( ) Other If Other, please explain: Number of brothers/sisters and their age: INSURANCE INFORMATION
(Please complete and give your insurance card to the receptionist.) Person responsible for bill:
Is this patient covered by insurance?
 Yes
 No
Primary Dental Insurance:
Secondary Dental Insurance
(if applicable):
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Patient Medical History
Now, or in the past, has the patient had?
Please explain any “yes” answers: _______________________________________________________________________________________ ___________________________________________________________________________________________________________________ Please list any medications being taken and reason, and also any significant past use of medications: Be sure to inform us if there is any current or past use of bisphosphonates. Bisphosphonates are a type of medication that can significantly impact orthodontic treatment. Some of the brand names are Fosamax, Actonel, Boniva, Skelid, Didronel, Aredia, and Zometa. Dental History
Now, or in the past, has patient had? “Extra” or missing teeth? Please explain any “yes” answers:_______________________________________________________________________________________ ___________________________________________________________________________________________________________________ Is antibiotic premedication needed for dental visits? Please careful y try to remember any significant dental history or any past traumatic events to face, chin, or teeth and describe:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Please describe any family history of jaw imbalances, jaw surgery, or other unusual dental problems:
___________________________________________________________________________________________________________________
Habits
Now, or in the past, has patient had?
Describe oral hygiene habits (brush/floss how many times/day): _______________________________________________________________
Women Only
Are you pregnant?
Do you anticipate becoming pregnant? yes
For Girls Only
For Boys Only
If yes, date: __________________________________ If yes, date: __________________________________ Have you seen an orthodontist previously? If yes, please explain:_______________________________________ If yes, explain type and date taken:____________________________ Anything else significant that you feel we should know? __________________________________________________________________________________________________________________ The above information is true to the best of my knowledge. I authorize Mountain View Orthodontics, LLC or my insurance company to release information to check my benefits and I understand, where appropriate, credit bureau reports may be obtained. I give consent to examination by the doctor and staff of Mountain View Orthodontics, LLC.

Source: http://www.mviewortho.com/doc/medical-history-form.pdf