Medical/Dental History
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Cell Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person completing this form (if patient is a minor)
First Name
Last Name
Relationship to patient
Mother
Father
Grandparent
Guardian
How did you hear about our office? Whom may we thank for referring you?
*
Medical History
Do you have or have you had any of the following (check all that apply)?
Rheumatic Fever
Heart Murmur
High Blood Pressure
Heart Attack/Stroke
Blood Disorder
Asthma
AIDS/HIV Infection
Hepatitis
Diabetes
Ulcers
Herpes (any type)
Cancer
Persistent Headaches
Respiratory Problems
Nerve or Brain Disease
Migraines
Epilepsy/Seizures
History of emotional or nervous disorder
Bone Disorders
Arthritis (any type)
Sleep Apnea
Ear Disorder
Sinus Infections
Swollen Glands
Seasonal Allergies
Other
Have you ever taken any of the following medications?
Phen-Phen
Phosphomax
Redux
Do you have any allergies or have you had any reactions to any of the following?
Aspirin
Sulfa Drugs, Sulfates, Sulfides
Penicillin or other antibiotics
Latex
Codeine
Metals
Novocain
Plastics
Other
Are you currently taking any medication?
*
Yes
No
Have you in the past or are you presently under the care of a psychiatrist or psychologist?
*
Yes
No
Does patient have any medical problems or history not mentioned above?
*
Yes
No
Please give explanation to any "yes" answers or conditions above.
Dental History
Dentist Name
Date of last dental check-up
*
-
Month
-
Day
Year
Date
Why are you seeking orthodontic treatment?
Has patient been treated for this condition before?
Yes
No
Please describe the diagnosis and treatment.
Please give names/ages of any other children in the household.
Has any other member of the family had orthodontics?
Yes
No
Has any other member of the family been treated by Dr. McElroy?
Yes
No
Name of family member
First Name
Last Name
Relationship to patient
Spouse
Mother
Father
Brother
Sister
Cousin
Do any of your teeth hurt?
No
Upper Right
Upper Left
Lower Right
Lower Left
Have any wisdom teeth been removed?
Yes
No
Number of wisdom teeth removed
Have ever been treated for periodontal disease (gum disease)?
Yes
No
Describe treatment for gum disease
Have you had any previous orthodontic treatment?
Yes
No
Name of orthodontist who provided treatment
Have there been any injuries to your mouth or teeth?
Yes
No
Please describe mouth/tooth injuries
Have there been any injuries or surgeries to the head and neck area?
Yes
No
Please describe head/neck injury or surgery
Do you clench or grind your teeth?
Yes
No
Do you ever feel pain, soreness, tightness, tiredness of the jaw muscles?
Yes
No
Please describe
Does is ever hurt to chew?
Yes
No
Please describe when/where pain occurs
Do you ever hear clicking, popping, or grating sounds in your jaw joint?
No
Clicking
Popping
Grating
Please describe
Do you have any of the following habits?
Finger / Thumbsucking
Lip Biting
Nail Biting
Gum Chewing
None of the above
Growth and Development
If patient is over 18 years of age, please skip to signature section
Has patient reached adolescent growth?
Yes
No
Girls - has monthly cycle started?
Yes
No
At what age did monthly cycle start?
Boys - has voice changed yet?
Yes
No
At what age did voice change?
Does the patient have any learning disabilities?
Yes
No
Learning Disability
I certify that the above medical and dental information is accurate. If there are any changes to this information, I understand that it is my responsibility to inform this office. I give my permission for a clinical examination.
*
Submit
Doctor Signature
Should be Empty: