Harmony Ortho NP Form (Adult)

	Yes	No
Does patient gag easily?
Does patient have frequent ear infections?
Have tonsils and adenoids been removed?

	Yes	No	Please explain:
Is there any dental work to be completed? (fillings, crowns, etc.)
Have there been any injuries to the face, mouth, or teeth?
Have you ever sucked your fingers or thumb? (Please indicate at what age?)
Does patient have any speech problems?
Have you ever had orthodontic treatment?
Has any family members had orthodontic treatment?
Are you a mouth breather?
Have you been informed of extra or missing permanent teeth?
Is there pain in the jaw? (please indicate right, left, or both?)
Is there popping or clicking in the jaw joint(s)? (Please indicate where the popping or clicking - right, left, or both?)
Do you clench or grind?
Do you regularly experience headaches? (please indicate how often)

Patient Medical History