Health History

*First Name:  
Middle Initial:
*Last Name:  
*Gender at birth:  
*Postal Code:
*Main Phone:  
2nd/Cell Phone:
Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
*First Name:  
Middle Initial:
*Last Name:  
*Postal Code:
*Main Phone:  
2nd/Cell Phone:
Relationship to Patient:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Work Phone #:
Dentist Name:
Phone Number:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consultation or treatment?
If so, when?
What is the patient's main orthodontic concern?
When did you last have dental x-rays?
Have you ever had implant surgery in one or both of your jaws or jaw joints?
If yes, who performed the surgery and when was it done?
Are you being followed up by a specialist?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?  
Grind or clench teeth?  
Oral habits (thumb/finger sucking, lip/nail biting)?  
Injury to face, jaw, teeth or mouth?  
Discomfort from teeth or gums?  
Pain, tenderness or noise in either jaw?  
Frequent headaches?  
Neck/shoulder pain?  
Frequent sore throats?  
Brush teeth daily?  
Floss teeth daily?  
Fluoride treatments?  
Mouth breathing?  
Snores during sleep?  
Requires premedication?  
Any missing or extra permanent teeth?  
Apprehensive about dental care?  
Frequently Chew Gum?  
Bad Breath?  
Bleeding Gums?  
Use of Tobacco Products?  
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Phone Number:
Date of last Physical:
Postal Code:
Patient Health:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. Congenital heart disease), or a heart transplant?
For women only: Are you breastfeeding or pregnant? If pregnant, when is your expected delivery date?
Do you have a prosthetic or artificial joint?
Do you chew or smoke any Tobacco products?
Do you drink Alcohol? If so, how many drinks a week?

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Rheumatic Fever  
Tuberculosis/Lung Disease  
Liver Disease  
Kidney Disease  
Heart Attack/Stroke  
Heart Disease  
Congenital Heart Defect  
Heart Murmur  
Hypertension/High Blood Pressure  
Prolonged Bleeding/Transfusion  
Tonsils/Adenoids Removed  
Family History of Cancer  
Received Radiation Treatment  
Growth Problems  
Endocrine Problems  
Hormone Therapy  
Latex/Metal Allergy  
Nervous Disorders  
Bone Disorders/Bone Loss  
Treated for Emotional Problems  
Ever Been Hospitalized  
Use of Recreational Drugs  
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
Parent/Guardian 1 Name:
Parent/Guardian 2 Name:
Has patient begun puberty:
Has patient been or is on hormone treatment transitioning?
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
Please list the name and birthdate of any siblings:
I, the undersigned, certify that I have provided an accurate and complete personal and medical / dental history and I have not knowingly omitted any information. I understand that consultation with my dentist or medical doctor may be required and I consent to my dentist or physician being contacted if necessary.