"Braces Make Beautiful Faces"

Thomas D. Jusino D.D.S.,M.S.

"The Smile Engineer"

Adult Medical History Form

Please download form, completely fill it out, and bring it to the initial visit appointment, or FAX (248) 476-3005

(There are 4 pages)

Today’s date:______________________

General Information

Patient name:_____________________ Age:_______ Date of Birth:________________

Sex: Male Female Social Security #:_______________________

Address:________________________________________________________________

______________________________________________ Tel.( )_________________

City State Zip

Marital status: Single Married Widowed Divorced Separated

Employer: _________________________________ How long there? ______________

Employer’s Address: _______________________________Work Tel.( )___________

Where and when are the best times to reach you? _______________________________

Whom may we Thank for referring you?_______________________________________

Names of other family members seen by us?____________________________________

Family Dentist:______________________ Last Visit Date:_______________________

Family Physician: _____________________ Last Visit Date: ______________________

What are your concerns about your teeth? ______________________________________

________________________________________________________________________

Medical History:

Have you had or do you have any of the following?

Y N Anemia Y N Heart surgery / Pacemaker

Y N Artificial Bones / Joints Y N Hemophilia / Abnormal Bleeding

Y N Artificial Valves Y N Hepatitis

Y N Asthma / Arthritis Y N High / Low Blood Pressure

Y N Blood Transfusion Y N HIV+ / AIDS

Y N Cancer / Chemotherapy Y N Hospitalized for Any Reason

Y N Congenital Heart Defects Y N Kidney Problems

Y N Diabetes / Tuberculosis Y N Mitral Valve Prolapse

Y N Difficulty Breathing Y N Psychiatric Problems

Y N Drug / Alcohol Abuse Y N Rheumatic / Scarlet Fever

Y N Emphysema / Glaucoma Y N Severe / Frequent Headaches

Y N Epilepsy/Seizures / Fainting Spells Y N Shingles

Y N Fever Blisters / Herpes Y N Sinus Problems

Y N Heart Attack / Stroke Y N Ulcers / Colitis

Y N Heart Murmur Y N Venereal Disease

Your current general health is: Good Fair Poor

Y N Are you currently under the care of a physician? If yes, reason ______________________________

Y N Are you currently taking any medication? If yes, describe __________________________________

Y N Are you allergic to any medications? (E.g.: aspirin, penicillin, etc.) If yes, _______________________

Y N Have you ever had any general anesthesia? When? ________________________________________

For Women:

Y N Are you taking birth control pills?

Y N Are you pregnant? Week # _________

Y N Are you nursing?

Dental History:

Y N Have you ever had or a serious/ difficult problem associated with past dental work?

Y N Do you now or have you ever experienced pain/discomfort in your jaw joint(TMJ)?

Y N Do you clench / grind your teeth?

Y N Have you ever had an injury to your: Mouth Teeth Chin (please circle)

Y N Do your jaw muscles ever feel tired? If yes, when __________________________

Y N Does it hurt to chew? If yes, when ______________________________________

Y N Do you hear clicking (popping) or grating sounds in your jaw joints?

Y N Have your jaws ever “locked” on you?

Y N Do you like your smile?

Y N Do your gums ever bleed? If yes, how often _______________________________

Y N Have you ever had treatment for periodontal disease (gum disease)?

Y N Do you have any missing or extra permanent teeth?

Your current dental health is: Good Fair Poor

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

____________________________________________________________

Signature Date

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.

_____________________________________________________________

Signature Date

Thank you for filling out this form completely.

INSURANCE INFORMATION

Primary:

Insurance Company Name: _______________________________________

Insurance Company Address: ______________________________________

Insurance Company Phone #: _______________________________________

Group # (Plan, Local or Policy #): ___________________________________

Insured’s Name: ______________________________ Relationship _________________

Insured’s Birthdate: ____/____/____ Insured’s SS #: _______________________

Insured’s Employer: _______________________________________________________