General Medical / Dental History

General Medical / Dental History
Which Office are you a Patient?*
Patient Name:
Date:

MonthDayYear
Date

Dental History
General dentist's name:
Last seen?
Reason for the appointment?
How often does patient see their general dentist per year?
Other Than Checkups is the patient in need of any Dental proceedures?

NoYes
Please explain Dental needs:
Has the Patient ever had a reaction to a dental procedure?

NoYes
Explain reaction to a dental procedure.

Medications and Allegies
Is the Patient Taking Any Medication including over the counter?

YesNo
List Medications Taken
Does the Patient Require antibiotics Prior to Dental Proceedures?

YesNo
Is the Patient allergic to any medications?

YesNo
If yes, list medication allergy?
Does the patient have any allergies including food or seasonal?

NoYes
What is the type of allergies?
Taking Medications for allergies including non-prescription

Breathing and Airway History
Does the Patient have a history of Asthma

NoYes
List medications for Astma.
Are the Tonsils Present?

NoYes
Date Removed and Doctor
Are the Adenoids Present?

NoYes
Date Removed and Doctor
Sex of Patient*

MaleFemale

Female Medical History
Have menses begun (monthly period)?

NoYes
Month/year menses began?
Are there Gynecological Problems?

NoYes
Explain Gynecological Problems.
Is the patient pregnant?

NoYes
Due Date

MonthDayYear
Date

Is the patient currently receiving, or has the patient ever received speech therapy? No Explain:

Patient/parental concerns: Previous orthodontic experience:
Patient/parental concerns:
Previous orthodontic experience:
To the best of my knowledge, I have answered the questions truthfully and accurately. I feel there is no other dental/medical history that I feel would be detrimental to receiving orthodontic treatment. I also understand it is my responsibility to make Orthodontists Associates aware of any changes to this dental/medical history.

Signature of patient/guardian (if minor)
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: