ADULT CASE HISTORY

GENERAL INFORMATION:

Date:

Patient Name:

Sex:

Male Female

Date of Birth:

Age:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email address:

Referral source:

Phone #:

Address:

Concerns/Reasons for referral:

Name of Primary Physician and address:

Name of General Dentist and address:

Name of Orthodontist and address:

Other Medical Specialists (Neurologist or Ear-Nose-Throat Physician, etc.):

INSURANCE INFORMATION

Health Insurance Company:

Policy Holder’s Name:

Policy Holder’s Date of Birth:

DEVELOPMENTAL HISTORY

Were there any problems during your mother’s pregnancy or difficulties with your delivery?

Were developmental milestones within normal limits? Or altered?

Were you bottle or breast fed? How long?

Were there initial feeding difficulties as an infant/toddler?

Have you ever sucked your:

Thumb

Finger

Pacifier

When did the habit stop?

Do you have a history of other oral habits and indicate if still present:

Lip Licking?

Lip sucking?

Cheek Biting/Sucking?

Nail biting?

Other oral habits?

PRESENT EATING HABITS:

Are you a fast or slow eater?

Do you drink more than one glass of liquid with meals?

Do you wash down food with liquids?

Do you chew your food adequately?

Do you choke easily?

Gag easily?

Do you belch often?

Do you have digestive problems?

History of reflux?

Are you a noisy eater (smacking)?

Messy eater?

Is there audible gulping when swallowing?

Do you chew with lips apart/mouth open?

Do you avoid any foods due to difficulty with chewing or do to texture sensitivities?

Do you have difficulties swallowing pills?

DENTAL HISTORY:

Were baby teeth normal?

Were baby teeth lost at normal ages?

History of any dental anomalies?

Do you have a history of cavities or periodontal disease?

Other dental concerns?

Have permanent teeth been injured/chipped/extracted?

List any prior orthodontic treatment you have received:

Do you experience any of the following:

Clicking of the jaw

Popping of the jaw

Pain in the jaw

Facial pain

Teeth bruxism (grinding of the teeth): Day

Teeth bruxism (grinding of the teeth): Night

Teeth clenching: Day

Teeth clenching: Night

MEDICAL HISTORY:

Please list age at diagnosis, severity, and any additional details:

Lingual Frenum Restriction (tongue tie)

Lip Tie

Buccal (Cheek) Ties

Enlarged Tonsils

Tonsillitis

Tonsillectomy

Enlarged Adenoids

Adenoidectomy

Middle Ear Infections

PE Ear Tubes

Ear Surgery

Hearing Loss

Allergies

Frequent Colds

Upper Respiratory Infections

Nasal Obstruction

Deviated Septum

Sinus Infections

Headaches/Migraines

Seizures

Head Injury

Snoring

Sleeping Issues

Jaw Pain/TMD

GERD-Acid Reflux

Heart Problems

High Fevers/Measles

Mumps

Other medical conditions not included above:

List any current prescriptions:

ADDITIONAL INFORMATION:

Are there specific questions you would like me to answer prior to the evaluation?

Is there anything else you would like me to know about you and your family history?

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