Medical History
Patient's First Name
Patient's Last Name
Patient's Age
Patient's Weight
Physician's Name
Physician's Phone Number
Date of last Exam
Please indicate any of the follow conditions for which the patient has been treated:
Rheumatic Fever or Rheumatic Heart Disease
Yes
No
Cardiovascular Disease (heart attack, heart murmur, coronary artery disease, high blood pressure, stroke, pacemaker)
Yes
No
Lung Disease (asthma, emphysema, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, sleep apnea)
Yes
No
Dizziness, seizures, epilepsy, or fainting
Yes
No
Bleeding disorders, anemia, prolonged bleeding
Yes
No
Liver Disease
Yes
No
Kidney Disease
Yes
No
Diabetes
Yes
No
Thyroid Disease
Yes
No
Arthritis
Yes
No
Hepatitis, B, C (check all that apply)
Yes
No
B
C
HIV/AIDS
Yes
No
Please list any and all medication taken, including prescription medications, over-the-counter, herbal or holistic remedies, vitamins or minerals:
150
Please list any and all known allergies/drug sensitivities
150
Dental History
Dentist's Name
Phone Number
Email
Date of Last Exam
Has the patient seen an orthodontist previously?
Yes
No
Name of previous Orthodontist
Has the patient ever sucked their thumb or finger?
Yes
No
Has the patient ever had speech problems?
Yes
No
Does the patient clench or grind their teeth?
Yes
No
Does the patient have pain or clicking when opening or closing their mouth?
Yes
No
Has the patient had any head or neck injuries?
Yes
No
Has the patient been informed of any missing or extra permanent teeth
Yes
No
Patient's Signature (if over 18)
*
Clear
Parent or Guardian's Signature (if under 18)
*
Clear
Today's Date
Submit
Powered by