Patient Name
*
Date of Birth
*
/
Month
/
Day
Year
Date
Physician's Name
Phone
Has patient ever been under the extended care of a physician or had any surgeries?
Yes
No
If yes, please explain:
Date of Last Physician's Visit
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 Breakdown
HIV Positive
Tuberculosis
Asthma
Epilepsy
Birth Defects
Infections
ADHD
Hepatitis
Frequent Headaches
Kidney Infections
Cerebral Palsy
Eyesight Problems
Speech Impairment
Autism
Other
Is the patient currently on any medications?
Yes
No
Is the patient allergic to any foods or medicines?
Yes
No
Has the patient ever taken or is currently taking any bisphosphonates?
Yes
No
If yes, list:
If yes, list
If yes, list
Last Dentist's Name
Date of Last Dental Visit
Dental and Orthodontic History
*
Yes
No
If applicable, please explain:
We 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?
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 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?
Has 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?
Any orthodontic concern?
Please describe patient's diet (regular/favorite foods)
Please tell us about patient's interests (favorite sports, hobbies, TV shows, travel, movies, etc.)
Phone
Date
-
Month
-
Day
Year
Date
Parent/Guardian Signature
Submit
Should be Empty: