Patient Information

First Name:
Last Name:

Dental History

For the following questions mark yes, no or don't know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Now or in the past, have you had:

Started teething very early or late?
Primary (baby) teeth removed that were not loose?
Permanent or 'extra' (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or otherwise injured primary (baby) or permanent teeth?
Teeth sensitive to hot or cold; teeth throb or ache?
Jaw fractures, cysts, or mouth infections?
'Dead teeth' or root canals treated?
Bleeding gums, bad taste or mouth odor?
Periodontal 'gum problems'?
Food impaction between teeth?
Thumb, finger, or sucking habit?
Until what age?
Abnormal swallowing habit (tongue thrusting)?
History of speech problems?
Mouth breathing habit, snoring, or difficulty in breathing?
Tooth grinding or jaw clinching?
Any pain in jaw or ringing in the ears?
Any pain or soreness in the muscles of the face or around the ears?
Difficulty encountered in chewing or jaw opening?
Aware of loose, broken or missing fillings?
Any teeth irritating cheek, lip, tongue or palate?
Concerned about spaced, crooked, or protuding teeth?
Aware of or concerned about under or over-developed jaw?
'Gum Boils', frequent canker sores or cold sores?
Taking any forms of flouride?
Any relative with similar tooth or jaw relationship?
Had periodontal (gum) treatment?
Would you object to wearing orthodontic appliances (braces) should they be indicated?
Any serious trouble associated with any previous dental treatment?
Ever had a prior orthodontic examination or treatment?
Been under another dentist's care?
Specialist:
Other:
How often do you brush?
How often do you floss?
What is your primary concern?

Medical History

For the following questions mark yes, no or don't know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

Now or in the past, have you had:

Birth defects or hereditary problems?
Bone fractures, any major accidents?
Rheumatoid or arthritic conditons?
Endocrine or thyroid problems?
Kidney problems?
Diabetes?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer or hyperactivity?
Polio, mononucleosis, pneumonia?
Problems of the immune system?
AIDS or HIV positive?
Hepatitis, jaundice, or liver problems?
Fainting spells, seizures, epilepsy or neurological problems?
Mental health disturbance or depression?
Vision, hearing, tasting or speech difficulties?
Loss of weight recently, poor appetite?
History of eating disorder (anorexia, bulimia)?
Excessive bleeding or bruising tendency, anemia, or bleeding disorder?
High/Low blood pressure?
Tired easily?
Chest pain, shortness of breath or swelling ankles?
Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur, or rheumatic heart disease)?
Skin disorder?
Do you eat a well-balanced diet?
Frequent headaches, colds, or sore throats?
Eye, ear, nose, or throat condition?
Hayfever, asthma, sinus trouble or hives?
Tonsil or adenoid condition or removal?
Allergies?
Specify:
Are you taking medication, nutritional supplements, herbal medications or non-prescription medicine?
Specify:
Do you currently have or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Operations?
Describe:
Hospitalized?
Describe:
Other physical problems or symptoms?
Describe:
Being treated by another health care professional?
For:
Date of most recent physical exam?
Are there any other medical conditions we should be aware of?
I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dentist status, I will so inform this practice.

I authorize the office, to perform necessary dental services that I may need at this appointment, including dental x-rays.
Signature:
Date
*By typing my name above I am electronically signing this form.