Confidential Patient Information
First Name:
Middle Initial:
Last Name:
Birthdate:
Medical History
Physician Name:
Date of Last Visit:
Phone:
Address:
City:
State:
Zip:
Please select YES or NO (If YES, please fill in details). Parents/Guardians please respond for minors.
YES
NO
Are you taking any medications/supplements/herbals?
YES
NO
Are you allergic to any medication/foods/latex/metals/acrylics/anestherics, etc.?
YES
NO
Do you have a history of a major illness?
YES
NO
Have you had any major operation?
YES
NO
Have you ever been involved in a serious accident?
YES
NO
Are you taking/have you taken bisphosphonates for osteoporosis or other bone diseases?
YES
NO
Do you chew or smoke tobacco products? If so, how long?
Please select YES or NO to any of the medical conditions below that you have had or currently have:
Abnormal Bleeding / Hemophilia?
YES
NO
Anemia?
YES
NO
Arthritis?
YES
NO
Asthma or Hayfever?
YES
NO
Bone Disorders?
YES
NO
Congenital Heart defect?
YES
NO
Diabetes?
YES
NO
Dizziness?
YES
NO
Epilepsy?
YES
NO
Gastrointestinal Disorder
YES
NO
Heart Problems / Heart Murmur?
YES
NO
Hepatitis / Liver Problems?
YES
NO
Herpes?
YES
NO
High Blood Pressure?
YES
NO
HIV / AIDS?
YES
NO
Kidney Problems?
YES
NO
Nervous Disorders?
YES
NO
Pneumonia?
YES
NO
Prolonged Bleeding?
YES
NO
Radiation / Chemotherapy?
YES
NO
Rheumatic Fever?
YES
NO
Sleep Apnea?
YES
NO
Tuberculosis?
YES
NO
Tumor or Cancer?
YES
NO
Are there any medical conditions we have not discussed that you feel we should be aware of?
Does your physician recommend premedicating with antibiotics prior to dental procedures?
YES
NO
Dental History
Dentist Name:
Last Dental Visit:
What concerns you most about your teeth?
Please select YES or NO (If YES, please fill in details). Parents/Guardians please respond for minors.
YES
NO
Are you happy with the appearence of your teeth?
YES
NO
Have you ever lost or chipped any teeth?
YES
NO
Have there been any injuries to face, mouth, or teeth?
YES
NO
Do you have any type of thumb or tongue habit?
YES
NO
Are you a mouth breather?
YES
NO
Do you snore loudly?
YES
NO
Have you been told you have a tongue thrust?
YES
NO
Are you aware of your jaw clicking or popping?
YES
NO
Do you grind or clench your teeth?
YES
NO
Have you ever experienced chronic ringing in your ears?
YES
NO
Are there any familial medical conditions we should know about?
Patients Under Age 16:
Height of parents?
Mom:
Dad:
Female Patients Only:
YES
NO
Are You Pregnant?
YES
NO
Has menstruation started (This is useful in monitoring/modifying growth of head and jaw bones)?
I have read and understand the above questions. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes to the medical or dental history, I will so inform this practice.
Signature: