Medical History Patient Form

Medical History Patient Form
Patient Information

To be completed by a Parent/Guardian if the patient is under 18 years of age)
To provide you with the highest standard of orthodontic care, it is essential to know your medical and dental history, as these factors may impact the success of your treatment. If you have any questions regarding the information we collect from you and hold in your records, please do not hesitate to ask us. We are acting in your best interest at all times. Please read our privacy policy for further information.
Patient Details
Title
Full Name*

First NameLast Name
Email*
example@example.com
School (if applicable)
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
MaleFemaleOther
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of the person completing this form (if different)
Relationship to the Patient (if applicable)
Relationship to Patient Signature
How did you hear about us?
Name/s of any other family members who have attended this practice
What is your main reason for seeking this consultation?
Whom may we thank for your referral?
Name of your general dentist
Practice name/ location
Phone number of your general dentist (if known)
When was your last appointment or last check-up (if known)
For the Parent/ Guardian
Parent 1
Mobile Number 1
Parent 2
Mobile Number 2
Guardian
Guardian Mobile
Person Responsible Financially
Title
Name

First NameLast Name
Address (if different from above)
Mobile Number (if different from above)
Patient Private Health Fund (if applicable)
Email address (if different from above)
Signature*
YesNo
YesNo
Has the patient inherited any facial or dental characteristics? (If yes, please detail)
Does the patient take any daily medications (including prescribed, over the counter, or naturopathic)? (If yes, please detail)*
Any allergy to any medicines, chemicals, or other substances (latex, penicillin, peanuts, etc.)? (If yes, please detail)*
ArthritisADHDAdenoids RemovedAutism Spectrum DisorderAnaemia, Leukemia or other blood disordersHeart Disease or ComplaintHeart murmur / Rheumatic FeverKidney problemsBleeding problemsMouth breathing due to nasal obstructionHigh or low blood pressureTonsils RemovedLung RemovedLung DiseaseContact with AIDS (HIV) virusCerebral PalseyEpilepsySpeech & Hearing Problem
Any other condlitions which may affect to undertake orthodontic treatment (please list)
HAS THE PATIENT
Had any significant health problems in the past? If yes, please detail
Any current health problems? If yes, please detail
YesNo
If yes to above, please detail
YesNo
Had any orthodontic treatment previously? If yes, please give details
Had an injury to the primary or permanent teeth? If yes, please give details
Had an injury to the face, jaws or chin? If yes, please give details
HAS THE PATIENT EVER
YesNo
YesNo
Should be Empty:

Medical History Patient Form

Patient Information

Patient Details

How did you hear about us?

For the Parent/ Guardian

Person Responsible Financially

HAS THE PATIENT

HAS THE PATIENT EVER