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MEDICAL HISTORY
Physician_______________________________________________ Date
of Last Visit____________________________
Address________________________________________________ Phone____________________________________
Please circle Yes or No (If Yes, please
fill in details)
Yes No Are you taking any medication? _________________________________________________________
Yes No Are you
allergic to any medication? ______________________________________________________
Yes No Do you have a history of a major
illness?__________________________________________________
Yes No Have you had any major operations?_____________________________________________________
Yes No Have you ever been involved in a
serious accident?__________________________________________
Circle
any of the medical conditions below that you have had or currently have.
Abnormal bleeding/Hemophilia Diabetes Hepatitis/Liver problems Pneumonia
Anemia Dizziness Herpes Prolonged
Bleeding
Arthritis Epilepsy High
Blood Pressure Radiation/Chemotherapy
Asthma or Hayfever Gastrointestinal
Disorders HIV / Aids Rheumatic
Fever
Bone Disorders Heart Problems Kidney problems Tuberculosis
Congenital Heart Defect Heart Murmur Nervous Disorders Tumor or Cancer
Are there any medical conditions we have not discussed that
you feel we should be aware of?_______________________
________________________________________________________________________________________________
DENTAL HISTORY
Dentist_________________________________________________ Date
of last visit____________________________
What concerns you most about your teeth?______________________________________________________________
Yes No Are you
presently in any dental pain?_____________________________________________________
Yes No Have you ever experienced any
unfavorable reaction to dentistry?________________________________
Yes No Have you ever lost or chipped any
teeth?___________________________________________________
Yes No Have there been any injuries to face,
mouth or teeth?_________________________________________
Yes No Is any part
of your mouth sensitive to temperature or pressure?_________________________________
Yes No Do your gums bleed when you brush?____________________________________________________
Yes No Do you have any type of thumb or
tongue habit?_____________________________________________
Yes No Are you a
mouth breather?_____________________________________________________________
Yes No Have you ever seen an orthodontist?
If yes, who and when?____________________________________
Yes No What is your
attitude toward receiving orthodontic treatment?___________________________________
Yes No Has anyone
in your family received orthodontic treatment?_____________________________________
How
did they feel about the result?______________________________________________________________
What
is your attitude toward receiving orthodontic treatment?__________________________________________
Yes No Do your teeth or jaws ever feel
uncomfortable when you awake in the morning?_____________________
Yes No Are you aware of your jaw clicking or
popping?______________________________________________
Yes No Are you
aware of clenching your teeth during the day?_________________________________________
Yes No Have you ever been told that you
grind your teeth?___________________________________________
Yes No Do you have “tension” headaches?_______________________________________________________
Yes No Have you ever experienced chronic
ringing in your ears?______________________________________
Yes No If the
patient is under age 16, height of parents? Mom______ Dad______
Yes No Are you
aware that some appointments will be during school/work hours?_________________________
Please
list some hobbies or interests___________________________________________________________
Female
Patients only:_________________________________________________________________
Yes No Are you
pregnant?____________________________________________________________________
Yes No Has
menstruation started?_____________________________________________________________
BENEFITS
Benefits of Orthodontics:
Aesthetics, Health and Function.
Orthodontics is a service that provides an improvement in the appearance
of the teeth, in the general function of the teeth, and in general dental
health. Teeth, gums and jaws are an intricate body part and can fail to respond
to treatment. If good oral hygiene is not practiced, tooth decay and enlarged
gums can result. Joint discomfort and root shortening are observed in a small
percentage of cases. Teeth change throughout our lifetime and there can be some
movement of teeth and some change after treatment. I have read and understand
this paragraph, I also understand that my diagnostic
records and my name may be used for educational and promotional purposes. I
have truthfully answered all the above questions and agree to inform this
office of any changes in my medical or dental history. In addition, I authorize Dr.
____________________ to perform a complete orthodontic evaluation.
Signature:___________________________________________ Date:___________________
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