Confidential Patient Medical and Dental History
Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician's Name
Phone
Format: (000) 000-0000.
Last Visit
Date of Last Visit
Has patient ever been under the extended care of a physician or had any surgeries?
Yes
No
If yes, please explain:
CHECK ANY OF THE FOLLOWING FOR WHICH THE PATIENT HAS BEEN TREATED
Heart Conditions (murmur, etc.)
Excessive Bleeding
Diabetes
Rheumatic Fever
Liver Problems
Cancer
Nervous Disorder
HIV Positive
Tuberculosis
Asthma
Epilepsy
Birth Defects
Infections
ADHD
Hepatitis
Frequent Headaches
Kidney Infections
Cerebral Palsy
Eyesight Problems
Speech Impairments
Autism
Other
Is the patient currently on any medications?
Yes
No
If yes, list
Is the patient allergic to any foods or medicines?
Yes
No
If yes, list
Last Dentist's Name
Phone
Format: (000) 000-0000.
Date of Last Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dental and Orthodontic History
Please answer the following questions:
*
Rows
Yes
No
Please Explain (if applicable):
Were any x-rays taken at patient's last dental visit?
Has patient had any problems with dental exams or treatment in the past?
Has patient had any cavities in the past?
Does patient brush their teeth daily?
Does patient currently take a fluoride supplement tablet, gels, rinses, etc.?
Does patient floss their teeth daily?
Has patient ever received local anesthetic?
Has patient ever had sealants placed?
If applicable: Has patient been diagnosed with tooth decay in past two years?
Has patient experienced any trauma to the teeth? (falls, blows, chips, etc.)
Has patient ever sucked thumbs or fingers?
Does patient have speech problems?
Has patient ever been informed of any extra or missing teeth?
Has patient ever had a previous orthodontic exam?
Have any family members ever needed orthodontics in the past?
Does patient have any pain in their jaw?
Does patient have any popping or clicking of the jaw joint?
Please describe patient's diet (regular/favorite foods):
Any orthodontic concern?
Please tell us about patient's interest (favorite sports, hobbies, TV shows, travel, movies, etc.)
Parent/Guardian Signature
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: