Joe E. Gibson, DDS, MS

Specialist in Orthodontics

& Dentofacial Orthopedics

Health History Form for Adult Patients

Please Print

Patient Name ______Male/Female Date______

Date of Birth______E-mail ______

PATIENT DENTAL HISTORY

Last Dental Visit ______

Baby teeth removed that were not loose YN

Permanent teeth removed YN

Congenitally missing teeth YN

Chipped or otherwise injured teeth YN

Teeth sensitive to hot or cold, throb or ache YN

Jaw fractures, cysts or mouth infections YN

Root canal treated teeth YN

Bleeding gums, bad taste, mouth odor YN

Periodontal “Gum” Problems YN

History thumb/finger sucking YN

Tongue Thrust habit YN

History of Mouthbreathing YN

Snoring YN

Tooth Grinding YN

Tonsils / Adenoids removed YN

Injury to Head, Jaws, Face or Teeth YN

Under or Over Developed Jaw YN

Previous Orthodontic Treatment YN

Patient Medical History

Date of Patient’s Last Medical Exam ______

HEART Problems YN

Heart Murmur / Pre medication required YN

Cancer or Tumors YN

Diabetes YN

Emotional / Behavioral problems YN

Asthma YN

Attention deficit (ADD) / Hyperactivity YN

Birth defects of hereditary problems YN

Bone Fractures or major accidents YN

Arthritic Conditions YN

Endocrine or Thyroid problems YN

Kidney Problems YN

Stomach Ulcers or hyperacidity YN

Polio, Mono, TB, Pneumonia YN

Immune System problems YN

AIDS or HIV positive YN

Blood disorders / bleeding problems YN

Epilepsy, Seizures, Fainting YN

Neurological problems YN

Hepatitis / Liver disease YN

Speech, hearing, vision problems YN

High or Low Blood Pressure YN

Frequent Headaches, colds, sore throats YN

Hayfever, sinus trouble, Allergies YN

Smoker or Smokeless Tobacco User YN

Female Patients: Pregnant or Thinking of Becoming Pregnant ? Y N

Is Patient taking any kind of Medication, nutrient supplements or non prescription medicine? Please name them all.

______

______

Is Patient ALLERGIC to any kind of Medication? ______

Continue on the Back

Does Patient have any other Allergies? ______

Has Patient been hospitalized for any reason? ______

Is Patient currently under a Physician’s care? If so, for what______

How often does patient brush his/her teeth? ______Floss? ______

Realizing that successful treatment greatly depends upon the patient’s complete cooperation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions handicaps or problems that might be encountered during treatment? ______

I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for

any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record

or medical/dental status, I will so inform this practice. I understand that where appropriate, credit bureau reports may be

obtainedfor healthcare purposes only.

______

Signature of patient / parent or guardian Date

Thank you for choosing our Office.

Dr. Joe Gibson, Jr. and Orthodontic Team Members