General Medical / Dental History

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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

Medications and Allegies
Is the Patient Taking Any Medication including over the counter?
List Medications Taken
Does the Patient Require antibiotics Prior to Dental Proceedures?
Is the Patient allergic to any medications?
If yes, list medication allergy?
Does the patient have any allergies including food or seasonal?
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
List medications for Astma.
Are the Tonsils Present?
Date Removed and Doctor
Are the Adenoids Present?
Date Removed and Doctor
Sex of Patient

Female Medical History
Have menses begun (monthly period)?
Month/year menses began?
Are there Gynecological Problems?
Explain Gynecological Problems.
Is the patient pregnant?
Due Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

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
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: