Health History Form
Patient Name:
*
First Name
Last Name
Nickname:
*
Sex:
*
School:
*
Grade:
*
Name and ages of other children in family:
*
Medical History
Is the patient in good health?
*
Yes
No
Pregnant?
*
Yes
No
Please check box if patient has or has had:
*
Heart trouble
High or low blood pressure
Heart murmur
Congenital heart lesion
Rheumatic fever
Circulatory problems
Anemia or hemophilia
Diabetes
Tuberculosis
Frequent headaches
Faintness / Dizziness
Malignancies
Ulcer
HIV Virus (AIDS)
Kidney problems
Epilepsy
Thyroid problems
Arthritis or joint swelling
Prolonged bleeding problems
Hepatitis or liver problems
Bone disorders
Endocrine problems
Asthma
Hay Fever
Emotional problems
Sinus problems
Tonsils or adenoid problems
Tonsils removed
Adenoid removed
None of the above
For each of the selected, please specify when they had it or when it started:
*
Physician Name:
*
Is patient under physician's care presently?
*
Yes
No
If yes, what is the reason?
List any other serious illnesses or major operations:
*
List any allergies or medications now being taken and reasons for them:
*
Does Patient need premedication prior to dental work?
*
Yes
No
If yes, please explain:
Does patient have tendency to colds?
*
Yes
No
Does patient have tendency to sore throats?
*
Yes
No
Does patient have tendency to ear infections?
*
Yes
No
Has patient reached puberty?
*
Yes
No
If patient is male, has their voice changed?
*
Yes
No
Patient isn't male
If patient is female, has menstruation started?
*
Yes
No
Patient isn't female
Describe patient's temperament:
*
Patient will probably be...
*
Eager to cooperate
Cooperative
Unwilling but will go along
Uncooperative
Dental History
Answer Yes or No to the following:
*
Rows
Yes
No
Any injuries to face?
Any injuries to mouth?
Any injuries to teeth?
Parts of mouth sensitive to temperature, pressure, food or drink?
Frequent canker (cold) sores?
Any extra permanent teeth?
Any missing permanent teeth?
Any teeth removed by extractions?
Bleeding or swollen gums?
Growths, swellings or sores in mouth?
Any speech problems?
Any hearing problems?
Mouth breathing when asleep?
Mouth breathing when awake?
Thumb/finger sucking?
Lip sucking?
Any pain on opening mouth?
Any clicking on opening mouth?
Difficulty in opening mouth widely?
Jaw ever locked?
Grinding or clenching of teeth?
Musical instruments played?
Headaches frequently?
Dentist Name:
*
Does patient visit dentist regularly?
*
Yes
No
Date of last dental visit
*
-
Month
-
Day
Year
Date
Has an orthodontist been consulted previously or has patient had previous orthodontic treatment?
*
Yes
No
If yes, please explain the reason:
Orthodontist Name:
What is the patient's (or parent's) primary concern (why are you here)?
*
Whom may be thank for referring you?
*
Signature (Parent's signature if minor):
*
Date:
*
-
Month
-
Day
Year
Date
I authorize the following individuals to act as appointed healthcare representatives with whom my child's health information may be discussed:
*
I have received and/or reviewed a copy of Wardlaw Orthodontics, P.A.'s Notice of Privacy Practices. (You may refuse to sign this acknowledgment.)
Yes
No
Guarantor Signature:
*
Date:
*
-
Month
-
Day
Year
Date
WARDLAW ORTHODONTICS RESERVES THE RIGHT TO REFUSE TREATMENT TO ANYONE.
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