Patient lives with (check all that apply)
General Information
had orthodontic treatment
had orthodontic treatment
had orthodontic treatment
had orthodontic treatment
Financial Responsibility
Dental Insurance
Does this policy have orthodontic benefits?
Does this policy have orthodontic benefits?
Medical Insurance
Other physicians/health care providers being seen now
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)?
Does your child eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, cold, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Does your child frequently breathe through your mouth?
Has your child eer taken intravenous biphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate), or Didronel (etidronate) for bone disorders?
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?
Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanant teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Frequent oral habits (sucking finger, chewing pen, etc)?
Teeth causing irratation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for TMU or TMD problems?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?
Patient Health Information
Do you think that any of your child's activities affect his/her face, teeth, or jaws? How?
List any medication, nutritional suppliments, herbal medications or non-prescription medicines, including flouride suppliments that your child takes.
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 child's medical or dental health.
Medical History Updates or Changes