MEDICAL HISTORY

Today's Date *

Month Day Year
Date
Name *

First Name Middle Name Last Name
Birthdate *

Month Day Year
Date
Parent/Guardian Name (if patient is under 18 years of age)

First Name Last Name
Relationship to patient

Parent Close relative Other
If other, please indicate how you are related:
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Indicate type of phone (for # listed above): *

Cell phone Landline Work Other
Email *
example@example.com
Emergency Contact
Name *

First Name Last Name
Relationship to patient: *
Phone Number *

Area Code Phone Number
MEDICAL HISTORY
Any drugs or medication currently in use? *
If yes, what? Please list. *
Are you under a doctor's care? *
If yes, why? *
Is there any history of major illness? *
If yes, what? *
Are there any drug sensitivities? *
If yes, please list: *
Do you have any allergies? (including nickel sensitivity) *
If yes, please list: *
Are you sensitive to latex? *
Do you have a tendency to colds, sore throats, or ear infections? *
Do you smoke? *
Do you have sleep apnea? *
Do you snore? *
Are you HIV positive? *
Are you pregnant? *
DENTAL HISTORY
Name of Dentist/Clinic: *
Date of last exam:

Month Day Year
Date
Have there been any injuries to the face, mouth or teeth? *
Have you ever had speech therapy? *
Are you a mouth breather? *
Were you or are you currently a thumb sucker? *
Have any teeth been extracted? *
If yes, why?
Have you had any adverse effect to dental anesthesia? *
Have you been treated for gum disease? *
Have you had previous orthodontic treatment or consultation? *
If yes, when?
Do you play any musical instrument? *
If yes, what type?
Do you clench or grind your teeth? *
Does your jaw click or pop? *
Is there difficulty opening wide? *
Does your jaw ever stick so you can't close? *
Does it hurt to chew? *
Is there pain in front of your ears? *
Is there cheek or temple pain? *
Do you suffer from headaches? *
Do you have neck or shoulder pain? *
What are your concerns about your teeth or jaw? *
I have completed this form to the best of my knowledge.
Signature

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Date

Month Day Year
Date
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Emergency Contact

MEDICAL HISTORY

DENTAL HISTORY