Instagram Facebook X-twitter

Contact: (289) 475 1011

Book Appointment

Adult Medical History Form

Adult patient medical and dental history form based on the uploaded 2024 source document.

PATIENT

Title
What sex were you assigned on your birth certificate?
What is your current gender identification?
Marital Status

CLOSEST RELATIVE

Closest Relative Title

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE — PRIMARY

Does the primary policy have orthodontic benefits?

DENTAL INSURANCE — SECONDARY

Does the secondary policy have orthodontic benefits?

MEDICAL INSURANCE

DENTIST

PHYSICIAN

GENERAL INFORMATION

PATIENT HEALTH INFORMATION

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.

Do you take antibiotic pre-medication before any dental procedures?
Have you chewed tobacco?
Have you smoked any substance or vaped?
Are you pregnant?
Are you trying to become pregnant?

MEDICAL HISTORY

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For each question choose Yes, No, or Don’t know / understand (DK/U).
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates as Zometa (zoledronic acid), Aredia (pamidronate) or Didronel (etidronate)?
Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?
Hereditary or developmental conditions?
Bone fractures, or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?
Have you experienced any weight change in the past several months?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

ALLERGIES / REACTIONS

Have you had allergies or reactions to: Latex (gloves, balloons)?
Have you had allergies or reactions to: Metals (jewelry, clothing snaps)?
Have you had allergies or reactions to: Acrylics?
Have you had allergies or reactions to: Local anesthetics (novocaine, lidocaine, xylocaine)?
Have you had allergies or reactions to: Aspirin?
Have you had allergies or reactions to: Ibuprofen (Motrin, Advil)?
Have you had allergies or reactions to: Penicillin?
Have you had allergies or reactions to: Other antibiotics?
Have you had allergies or reactions to: Plant pollens?

DENTAL HISTORY

Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
“Gum boils,” frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for “TMJ” or “TMD” problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

FAMILY MEDICAL HISTORY

Have your parents or siblings ever had any of the following health problems? If so, please explain.

RELEASE AND WAIVER

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.

Adult New Patient Registration Form

Book Appointment

EXCITING NEWS FROM ORIS DENTAL CLINICS!

We’re excited to announce that Orthodontics is now available at Oris! Please join us in welcoming Dr. Arash Poursattar Bejehmir, Orthodontist, who will be joining our team beginning September 10, 2026.
Whether you’re considering orthodontic treatment for your child, your teen, or yourself, we’re happy to make your care even more convenient — right here at Oris Dental Clinics.

Orthodontic consultations are available for:
• Crowded or crooked teeth
• Gaps and spacing
• Overbites, underbites and other bite concerns
• Braces, clear aligners, and orthodontic treatment options
• Children, teens and adults

Back-to-school is the perfect time to start thinking about a healthier, more confident smile!
Appointments are now being booked for September 10th.

Contact our office today to reserve your Orthodontic Consultation.

Click here

Oris Dental Clinics
Your smile. Our specialists. All in one place.