Health History
Patient Biographical Information
*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
Male
Female
*Pronoun:
He/Him
She/Her
They/Them
*Address:
*City:
*Province:
*Postal Code:
*Main Phone:
2nd/Cell Phone:
Email:
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?
Financial Party Information
Check if the patient is also the person who will be financially responsible for treatment.
*First Name:
Middle Initial:
*Last Name:
*Address:
*City:
*Province:
*Postal Code:
*Main Phone:
2nd/Cell Phone:
Email:
Relationship to Patient:
Father
Grandparent
Guardian
Mother
Parents
Self
Spouse
Step Father
Step Mother
Other
Do you have insurance that covers orthodontics?
No
Yes
If so, please name the Insurance Company below:
Employer:
Occupation:
Work Phone #:
Dental History
Dentist Name:
Address:
Phone Number:
Check-up Frequency:
Once per year
Twice per year
More than twice a year
Never
Emergencies only
Last Dental Visit:
Has the patient had an orthodontic consultation or treatment?
No
Yes
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?
No
Yes
If yes, who performed the surgery and when was it done?
Are you being followed up by a specialist?
No
Yes
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?
No
Yes
Grind or clench teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Neck/shoulder pain?
No
Yes
Frequent sore throats?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Fluoride treatments?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Requires premedication?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Frequently Chew Gum?
No
Yes
Bad Breath?
No
Yes
Bleeding Gums?
No
Yes
Use of Tobacco Products?
No
Yes
If any of the above dental questions were answered 'Yes', please explain:
Medical History
Physician Name:
Phone Number:
Date of last Physical:
Address:
City:
Province:
Postal Code:
Patient Health:
Good
Excellent
Fair
Poor
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
No
Yes
Tuberculosis/Lung Disease
No
Yes
Pneumonia
No
Yes
Liver Disease
No
Yes
Kidney Disease
No
Yes
Heart Attack/Stroke
No
Yes
Heart Disease
No
Yes
Congenital Heart Defect
No
Yes
Heart Murmur
No
Yes
Hemophilia
No
Yes
Hypertension/High Blood Pressure
No
Yes
Prolonged Bleeding/Transfusion
No
Yes
Anemia
No
Yes
HIV/AIDS
No
Yes
Hepatitis
No
Yes
Tonsils/Adenoids Removed
No
Yes
Cancer
No
Yes
Family History of Cancer
No
Yes
Received Radiation Treatment
No
Yes
Growth Problems
No
Yes
Endocrine Problems
No
Yes
Hormone Therapy
No
Yes
Latex/Metal Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Diabetes
No
Yes
Seizures/Epilepsy
No
Yes
Handicaps/Disabilities
No
Yes
Asthma
No
Yes
Arthritis
No
Yes
Treated for Emotional Problems
No
Yes
Ever Been Hospitalized
No
Yes
Allergies
No
Yes
STDs
No
Yes
Use of Recreational Drugs
No
Yes
If any of the above medical questions were answered 'Yes' , please explain:
Patients Under 18
If patient is under the age of 18, please answer the following questions:
Height:
Weight:
School:
Grade:
Parent/Guardian 1 Name:
Parent/Guardian 2 Name:
Has patient begun puberty:
No
Yes
If patient is a girl, has menstruation begun:
No
Yes
If patient is a boy, has their voice changed or have facial hair:
No
Yes
Has the patient grown in the past year or has their shoe size changed recently:
No
Yes
Patient's interest in treatment:
Patient wants treatment
Patient unwilling, but agrees
Treatment only if necessary
Patient un-cooperative
Has either biological parent ever had orthodontic treatment:
Don't Know
Yes
No
Please list the name and birthdate of any siblings:
Patient Release:
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.
Signature:
