SDS_MedicalHistory

Patient Name*
Date of Birth*

MonthDayYear
Date
Physician's Name
Phone
Format: (000) 000-0000.
YesNo
If yes, please explain:
Date of Last Physician's Visit
Heart Conditions (murmur, etc.)Excessive BleedingDiabetesRheumatic FeverLiver ProblemsCancerNervous BreakdownHIV PositiveTuberculosisAsthmaEpilepsyBirth DefectsInfectionsADHDHepatitisFrequent HeadachesKidney InfectionsCerebral PalsyEyesight ProblemsSpeech ImpairmentAutismOther
YesNo
YesNo
YesNo
If yes, list:
If yes, list
If yes, list
Last Dentist's Name
Date of Last Dental Visit

Dental and Orthodontic History*

Rows	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
Format: (000) 000-0000.
Date

MonthDayYear
Date
Parent/Guardian Signature
Should be Empty: