Medical History Form

Medical History Form

The following patient information and health history is to be completed by adult patients or a parent/guardian of a minor.
Patient’s Name*
Birth Date*

MonthDayYear
Age*
Patient's Sex (Assigned at Birth)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone*
Work Phone
Email Address
Emails are only used for appointment and patient communication, your email will only be store internally.
Marital status of parents (if patient is a minor) or yourself*
Who will be the person finacially responsible for this patient?*
What is their relationship to the patient?*
What is the name of you/your families dentist?
Dentist Name and/or Office Name
When was the last time you/the patient was last seen by a dentist?

MonthDayYear
Date
How did you hear about us?
Has the patient been seen by another orthodontist?*

YesNo
What orthodontist did you/they see and when?
Names and ages of other children in family
Have they had any orthodontic treatment?
If so, with whom and when?
Chief Complaint (i.e. why do you want orthodontic treatment)?
Have there been any accidents that damaged the face, teeth, or jaws?
Have you been informed of any missing or extra permanent teeth?*

YesNo
Is there any treatment that has been recommended by the patient’s dentist?*

YesNo
Brush teeth daily?*

YesNo
Does the patient:

Thumb/finger suckMouth breatheTongue ThrustGrind or Clench TeethNail BitingLip Biting/SuckingTonsils &/or Adenoids removedPain, clicking, or locking of jaw joint (TMJ/TMD)Play musical instrument
Is the patient currently in good physical Health?*

YesNo
Has the patient experienced any of the following medical problems or conditions?
Abnormal bleeding, hemophilia, or anemia

YesNo
ADD/ADHD

YesNo
Alcohol or Drug Abuse

YesNo
Any hospital stays or operations

YesNo
Arthritis

YesNo
Artificial Bones/Joints/Valves

YesNo
Asthma, hay fever, or sinusitis

YesNo
Autism or Autism Spectrum Disorders

YesNo
Autoimmune disorders (lupus, etc.)

YesNo
Cancer, chemotherapy, or radiation

YesNo
Congenital Heart Defect

YesNo
Diabetes

YesNo
Digestive problems, ulcers, colitis, etc.

YesNo
Dizziness or fainting spells

YesNo
Ear or eye trouble other than corrective lenses

YesNo
Epilepsy, seizures, or convulsions

YesNo
Frequent headaches

YesNo
Handicaps or disabilities

YesNo
Heart problems, heart murmur, or mitral valve prolapse

YesNo
Pre-medication required for dental procedures?

YesNo
Hepatitis, jaundice, or liver problems

YesNo
High or low blood pressure

YesNo
HIV+ or AIDS

YesNo
Kidney or bladder problems

YesNo
Pacemaker

YesNo
Periodontal or gum disease

YesNo
Pregnancy (current)

YesNo
Problems with Novocain or anesthetics

YesNo
Psychiatric problems

YesNo
Respiratory problems or disorders

YesNo
Rheumatic/Scarlet Fever

YesNo
Skin Problems

YesNo
Stroke

YesNo
Thyroid or endocrine problems

YesNo
Tuberculosis (TB)

YesNo
Venereal Disease

YesNo
Please list any other serious medical problem
Any allergies (ie: Latex, Nickel/Metal, etc)?*

YesNo
Please list any allergies
Please list any medications
Insurance Information
Patient’s or Father’s Name
Address
Telephone
SSN
Birth Date

MonthDayYear
Date
Employer
Insurance Company
Insurance ID
Spouse’s or Mother’s Name
Address
Telephone
SSN
Birth Date

MonthDayYear
Date
Employer
Insurance Company
Insurance ID
Preferred Office Location*

Williamsville - 8650 Sheridan DrBlasdell - 3720 South Park AveAttica - 3325 E. Main StWarsaw - 34 Duncan St
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes to the patient’s (self or child’s) medical status.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Medical History Form

Has the patient experienced any of the following medical problems or conditions?

Insurance Information