Adult Orthodonic Health History

* - required information
If information not available please enter "None" or "Unknown"

About You
Today's Date:	12/21/2024
E-Mail Address:
Name:
* Last:
* First:
MI:
	Mr Mrs Ms Dr
I prefer to be called:
	Male Female
Birthdate:
Age:
SS #:
Home Address:
City:
State:
Zip:
Single Married Divorced Widowed Separated
* Hm #:
Pager/Other #:
Wk #:
Ext:
DL #:

Employer:
Employer's Address:
How long there?
Occupation:
Where & when are best times to reach you?
* Whom may we Thank for referring you?
Other family members seen by us:
General Dentist:
Last Visit Date:

Spouse Information
His/Her Name:
Employer:
Wk #:
Ext:
SS #:
Birthdate:

Person Responsible for Account:
Wk #:
Ext:
Hm #:
Billing Address:
Relation:
SS #:
Employer:
DL #:

Orthodontic Insurance
Primary
Orthodontic Coverage:	Yes No
Dental Coverage:	Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS #:
Insured's Employer:
Secondary
Orthodontic Coverage:	Yes No
Dental Coverage:	Yes No
Insurance Co. Name:
Insurance Co. Address:
Insurance Co. Phone #:
Group # (Plan, Local or Policy #):
Insured's Name:
Relation:
Insured's Birthdate:
Insured's SS #:
Insured's Employer:

In the event of an emergency, is ther someone who lives near you that we should contact?
His/Her Name:
Relation:
Wk #:
Hm #:

Medical History
Do you have a personal physician?	Yes No
Physician's Name:
Phone #:
Date of last visit:
Your current physical health is:	Good Fair Poor
Are you currently under the care of a physician?	Yes No
Please explain:
Are you taking any prescription / over-the-counter drugs?	Yes No
Please list each one:
For Women:
Are you taking birth control pills?	Yes No
Are you pregnant?	Yes No
Week #:
Are you nursing?	Yes No

Have you ever had any of the following diseases or medical problems?
Abnormal Bleeding Anemia / Radiation Treatment Artificial Bones / Joints / Valves Asthma / Arthritis Blood Transfusion Cancer / Chemotherapy Congenital Heart Defect Diabetes / Tuberculosis (TB) Difficulty Breathing Drug / Alcohol Abuse Emphysema / Glaucoma Epilepsy / Seizures / Fainting Fever Blisters / Herpes Heart Attack / Stroke Heart Murmur	Heart Surgery / Pacemaker Hemophilia Hepatitis High / Low Blood Pressure HIV⁺ / AIDS Hospitalized for Any Reason Kidney Problems Mitral Valve Prolapse Psychiatric Problems Rheumatic / Scarlet Fever Severe / Frequent Headaches Shingles Sinus Problems Ulcers / Colitis Venereal Disease

Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?
Aspirin Any Metals/Plastics Codeine	Dental Anesthetics Erythromycin Latex	Penicillin Tetracycline Other
Please list any other drugs/materials that you are allergic to:

Dental History
What are the main concerns that you would like orthodontics to accomplish?

Have you ever had or been evaluated for orthodontic treatment?	Yes No
Have you ever had a serious / difficult problem associated with any previous dental work?	Yes No
Do you now or have you ever experienced pain / discomfort in your jaw joint (TMJ / TMD)?	Yes No
Your current dental health is:	Good Fair Poor
Do you like your smile?	Yes No
Gums ever bleed?	Yes No
Have you ever had an injury to your:	Mouth Teeth Chin
Do you have any speech problems?

Do you generaly breath through your mouth?	Yes No
If yes:	While Awake? While Asleep?
Do you have any missing or extra permanent teeth?	Yes No

	I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medial status.

	I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Thank you for filling out this form completely.

	This office reserves the right to verify the credit status of potential patients and / or parents of patients prior to extending credit for treatment fees and may, at the discretion of the office, use the services of one or more credit reporting services.

	If this office accepts insurance, I understand that I am responsible for payments of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

9350 Waukegan Road
Morton Grove, IL 60053
847.470.0850
nscdh@smilesforyou.com