Marital status
Close Relative
Other physicians/health care providers being seen now
General Information
Financial Responsibility
Dental Insurance
Does this policy have orthodontic benefits?
Does this policy have orthodontic benefits?
Medical Insurance
Medical History
Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u).
Now or in the past, have you had:
Birth defects or hereditry problems?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low blood sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice, or any other liver problems?
Polio, mononucleosis, tuberculosis, or pneumonia?
Seizures, fainting spells, neurolgic problems?
Mental health disturbance or depression?
Vision, hearing or speech problems?
History of eating disorder (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breathe, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, cold, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?
Have you had allergies or reactions to any of the following?
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Other antibiotics
Ibuprofen (Motrin, Advil)
Plant pollens
Other substances
Dental History
Now or in the past, have you had?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanant teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Gum boils, frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?
Mouth breathing habit or snoring at night?
Frequent oral habits(sucking finger, chewing pen, etc)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for TMU or TMD problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?
Patient Health Information
Now or in the past, have you had?
Women: Are you pregnant
Are you trying to become pregnant
Family Medical History
Release and Waiver
I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.
Medical History Updates or Changes