CONFIDENTIAL

Medical/Dental History Form
Children

Patient Information

* Patient's Last Name:
* First Name:
* Middle Initial:
* Birthdate:
Sex:
Home Phone:
Mobile Phone:
* Patient's Address:
* City:
* State:
* Postal Code:

Responsible Party

* First Name:
* Last Name:
* Phone:
* His/Her Address:
* City:
* State:
* Postal Code:
Parent/Guardian Name:
Phone:
Parent is:
Father's Height:
Mother's Height:

Patient's Dentist

Name:
Practice Name:
Address:
Phone:

Patient's General Medical Practitioner

Name:
Practice Name:
Address:
Phone:

General Info

Number of brothers and sisters:
Ages:
Other family members treated:
Patient's Birth Weight:
Present Weight:
Height:
Patient's School:
Grade:
Musical Instrument(s) Played:
Favorite Sports, Hobbies and Avocations:
Insurance Coverage:
Email Address:

In case we cannot reach you, person to contact

Name:
Phone:

Medical History

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don’t know/understand (dk/u).

DK/U = Don't Know/Understand

Does patient follow directions?
Does patient brush his/her teeth conscientiously?
Does this patient have learning disabilities or need extra help with instructions?
Is patient sensitive, self conscious?
Birth defects or hereditary problems?
Bone fractures, any major accidents?
Rheumatoid or arthritic conditions?
Mental health or behavioural problems?
Vision, hearing, tasting, or speech difficulties?
Loss of weight recently, poor appetite?
Excessive bleeding, black and blue tendency, anemia, or bleeding disorder?
High or low blood pressure?
Easily tired?
Chest pain, shortness of breath, or swelling ankles?
Skin disorder?
Does the patient have a normal and good diet?
Frequent headaches, colds, or sore throats?
Eye, ear, nose, throat condition?
Hayfever, asthma, sinus trouble, hives?
Tonsil or adenoid conditions?
Allergies or drug reactions?
Does the patient currently have or ever had a substance abuse problem?
Other physical problems or symptoms?
Operations (Surgical Procedures)?
Cardiovascular problems (hear trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, or rheumatic heart)?
Has the patient ever been Hospitalized?
If yes, hospitalized for:
Are you taking medication, nutrient supplements, or non-prescription medicine?
If yes, please name them:
Being treated by another health care professional?
If yes, being treated for:
Date of the most recent physical exam:

Dental History

Now or in the past, has the patient had:

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Jaw fractures, cysts, infections
Any teeth treated with root canals or pupotomies?
Bleeding gums, bad taste, mouth odor?
Periodontal "Gum Problems"?
Food impaction between teeth?
"Gum Boils", frequent canker sores, cold sores?
Is child taking any forms of fluoride?
Frequent oral habits (sucking finger, chewing gum, etc.)
Teeth causing irritation to lip, cheek, or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Has patient ever had a prior orthodontic examination or treatment?
Has patient ever had periodontal treatment?
Has patient recently been under another specialist's care?
Specialist:
Reason:
Would patient object to wearing orthodontic appliances (braces) should they be indicated?
Date of last dental examination:
How often does your child brush?
How often does your child floss?
What is the primary concern - why are you here?
Realizing that successful treatment greatly depends upon the patient's complete co-operation in following instructions, keeping appointments, and maintaining oral hygiene, are there any restrictions, handicaps, or problems that might be encountered during treatment?
I have read and understand the above questions. I will not hold my orthodontist or any member of the staff responsible for any errors or omissions that I have maded in the completion of this form. If there are any changes later to this history record or medical/dental status, I will so inform this practice.