Orthodontic Medical History Form

1
May we have your name please?* This field is required.
Prefix
First Name
Last Name
2
Your date of birth?* This field is required.Type in or use calendar
Date
Day
Month
Year
3
What is your full address?* This field is required.
Street Address
Street Address Line 2
City
County
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
What is your email address?* This field is required.
example@example.com
5
What is the best contact number for you?* This field is required.
Please enter a valid phone number.
6
Please let us know below if you give consent to us leaving voicemails on your home phone with the understanding this may be heard by members of your family.* This field is required.
I consentI don't consent
7
What is your occupation?
8
Are you under the age of 18?* This field is required.If yes, please provide details of the parent/guardian
YESNO
9
Okay, thanks. Could you please provide the details of their parent/guardian?
10
Parent/Guardian's full name?* This field is required.
Prefix
First Name
Last Name
11
Parent/Guardian's relationship to the child?* This field is required.
12
Parent/Guardian's phone number?* This field is required.
Please enter a valid phone number.
13
Is there anyone else for whom you give consent to discuss your treatment?* This field is required.
YESNO
14
Great, could you please provide their details. What is...
15
their full name?* This field is required.
Prefix
First Name
Last Name
16
their relationship to you?* This field is required.
17
their phone number?* This field is required.
Please enter a valid phone number.
18
During your treatment we would like to keep your dentist informed, do you give consent to discuss your treatment?* This field is required.
YESNO
19
Could you please provide your dentist's name* This field is required.
Prefix
First Name
Last Name
20
Your dentist's practice name* This field is required.
21
Your dentist's practice phone number* This field is required.
Please enter a valid phone number.
22
Your dentist's practice address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
23
Thanks for that! Now, we just need ask some medical questions.
24
Do you have any problems with your heart or blood pressure?* This field is required.
YESNO
25
Do you have any chest or breathing problems?* This field is required.
YESNO
26
Are you epileptic or diabetic?* This field is required.
Epileptic
Diabetic
Both
Neither
27
Have you ever been diagnosed with "weak bones" or osteoporosis?* This field is required.
YESNO
28
Do you take any regular medication, including immunosuppressants?* This field is required.
YESNO
29
What are they?* This field is required.
30
Are you allergic to any medication (including penicillin) or to latex?* This field is required.
YESNO
31
What are they?* This field is required.
32
Do you have any other allergies?* This field is required.
YESNO
33
What are they?* This field is required.
34
Do you have any problems with your stomach when taking medication?* This field is required.
YESNO
35
Do you have any problems with excessive bleeding?* This field is required.
YESNO
36
Are you pregnant or trying to conceive?* This field is required.
YESNO
37
Have you ever had any form or cancer?* This field is required.
YESNO
38
Please provide details of this and treatments* This field is required.
Huge
Large
Normal
Small
Ok
Ok
39
Have you ever had any major operations or serious illness?* This field is required.
YESNO
40
Please provide details these* This field is required.
Huge
Large
Normal
Small
Ok
Ok
41
Do you smoke, vape or use e-cigarettes?* This field is required.
YESNO
42
Have you given up smoking in the last 2 years?* This field is required.
YESNO
43
Is the anything else about your medical history that you think we should know?* This field is required.
YESNO
44
Please provide details here* This field is required.
Huge
Large
Normal
Small
Ok
Ok
45
Ok, thanks. Last few questions.
46
What concerns do you have about your smile?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
47
How would you rate your smile?* This field is required.1-10 (10 being very good)
1
2
3
4
5
6
7
8
9
10
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1
2
3
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6
7
8
9
10
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6Row 0, Column 7Row 0, Column 8Row 0, Column 9
48
Have you had orthodontic treatment before?* This field is required.
YESNO
49
Is there a particular type of treatment or brace you are interested in?* This field is required.If yes, please describe the treatment/brace that you are interested in
50
Your personal data will never be passed to third parties unless we are making a professional referral for you. If we have your consent for referral to another health care provider we will send them just the information that they need to provide the necessary assessments, tests or treatment.* This field is required.
I acceptI don't accept
51
Please type your name as a Signature to confirm the information provided is true to the best of your knowledge.* This field is required.
52
Who completed this form?* This field is required.
Yourself
Parent/Guardian
Should be Empty: