Health History Form for Adult Patients
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