Update Medical History

Name

First NameLast Name

Today's Date

Date

Please check Yes or No if the patient has the following conditions:

Rows	Yes	No
Joint Swelling
Bone Disorders
Heart Trouble
Rheumatic Fever
Thyroid Problems
Diabetes
Hepatitis
Emotional Problems
Brain Injury
Kidney or Liver Involvement
AIDS/AIDS-Related Complex
Tuberculosis
Anemia
Asthma
Epilepsy
Prolonged Bleeding
Faintness or Dizziness
Tonsils Removed
Tonsilitis
Adenoids Removed
Sore Throats
Ear Aches

Other conditions or medical issues not listed above?

Please describe any other medical issues:

Any injuries to the face, mouth, or teeth?

Mouth-breathing when asleep, awake?

More than average amount of tooth decay?

Any missing permanent teeth?

Any extra permanent teeth?

Any teeth removed by extraction?

Visits dentist regularly?

Date of Last Visit

Date

Dentist

Phone Number of Dental Office

Please enter a valid phone number.Format: (000) 000-0000.

Has consulted an orthodontist before?

Please describe:

Is this visit for a second opinion?

Family history of under-bite (strong lower jaw)?

History of thumb/finger sucking habit?

Has history of speech therapy?

Any difficulty swallowing or chewing?

Any pain of clicking while opening mouth?

Plays sports?

Please list:

Uses mouth guards during sports?

Physician's Name

Phone Number of Physician's Office

Please enter a valid phone number.Format: (000) 000-0000.

Drug allergies (penicillin, dental anesthetic, aspirin, etc.)?

Please describe:

Other allergies (latex, gluten, peanuts)?

Please describe:

Drugs or other medications now being taken?

Please list medications:

Requires antibiotic pre-medication prior to dental procedures?

Parent's Attitude About Orthodontic Care

ACKNOWLEDGMENT

In completing this form, I understand that the information I have provided is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence, and it is my responsibility to inform this office of any changes in patient information or medical status.

Signature

Date

Dr. Melanie's Signature

Update Medical History

MEDICAL HISTORY