Please answer these questions for the person that is interested in treatment
(yourself or your child) as best as you can.

Patient Name:

Condition of your or your child’s general health:

Physician:

Phone #:

Family Dentist:

Phone #:

PLEASE ANSWER ALL QUESTIONS

Rows	Yes	No
Do you or your child have regular medical exams?
Are you or your child up to date with immunizations?
Have you or your child been hospitalized?
Have you or your child ever had general anesthesia or sedation for medical reasons?
Are you or your child presently taking medications?
Have you or your child ever had blood transfusions?
Are you or your child presently undergoing any medical treatment?
Are you or your child presently undergoing chemotherapy?
Do you or your child have an infectious or chronic disease?
Do you or your child smoke or use tobacco products?
Are you or your child allergic to any medicine?
Are you or your child allergic to Latex?
Have you or your child experienced unfavorable reactions from previous care?

If you or your child have been hospitalized:

Date

Reason

If you or your child had/have general anesthesia or sedation for medical reasons:

Date

Reason

If you or your child are presently taking medications, what medications are you taking?

If you or your child are presently undergoing any medical treatment, please list below:

If you or your child have an infectious or chronic disease, please list below:

If you or your child are allergic to any medicine, please explain:

If you or your child have experienced unfavorable reactions from previous care, please explain:

Have you or your child ever been diagnosed with any of the following conditions:

Rows	Yes	No
Blood-Circulatory
Bones
Endocrine Glands
Eyes, Ears, Nose
Gastrointestinal-Stomach
Heart
Kidney-Bladder
Liver
Muscles
Nervous System
Prosthetic Valves & Joints
Respiratory
Skin Throat
Tonsils/Adenoids
AIDS
Anemia
Allergy
Arthritis
Asthma
Autism

Rows	Yes	No
Brain Injury
Bronchitis
Cancer
Cerebral Palsy
Chicken Pox
Cleft Lip/Palate
Convulsions/Seizures
Diabetes
Diphtheria
Drug or Alcohol Abuse
Epilepsy
Eye Problems
Excessive Bleeding Problems
Fainting
Hearing Loss
Heart Disease/Heart Murmur
Hemophilia
Hepatitis
Hyperactivity
Jaundice

Rows	Yes	No
Kawasaki Disease
Leukemia
Measles
Mumps
Pregnant
Psychiatric Disorder
Rheumatic Fever
Scarlet Fever
Scoliosis
Sickle Cell Anemia
Sinus Problems
Sore Throat
Speech Therapy
Spina Bifida
Syndrome
Tetanus
Tuberculosis
Venereal Disease
Diphtheria
Whooping Cough

Additional conditions information:

Dental Health History

Rows	Yes	No
Do you or your child have a dental condition about which you are especially concerned?
Have you or your child ever received injuries to the head, jaw, mouth or teeth?
Were you or your child a thumb/finger sucker?
Do you or your child grind or clinch his/her teeth?
Do you or your child’s gums bleed?

Explain if you or your child have a dental condition about which you are especially concerned.

Explain if you or your child have received injuries to the head, jaw, mouth or teeth.

Age discontinued if you or your child were a thumb/finger sucker.

What is your water source?

Other

How often are you or your child’s teeth brushed per day?

By whom?

What type toothpaste?

Thank you for your help. If there is any information that you think might be of value to us in treating you or your child, please feel free to comment. I certify that I have read and understand the above questions. I will not hold the staff of Burns Orthodontics responsible for any errors or omissions I may have made in the completion of this form.

Signature of Parent/Legal Guardian:

Relationship to Patient

Witness Signature:

Date:

Please verify that you are human

Please answer these questions for the person that is interested in treatment (yourself or your child) as best as you can.

Dental Health History

Please answer these questions for the person that is interested in treatment
(yourself or your child) as best as you can.