Medical Dental History Form for Patients Under 18

PrefixFirst NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

PrefixFirst NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

PrefixFirst NameLast Name

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter a valid phone number.Format: (000) 000-0000.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name blank City, Stateblank Reason blank
Name blank City, Stateblank Reason blank

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 mark yes, no, or don't know/understand (dk/u).

List any medication, nutritional supplements, herbal medications, or non-prescription medicines, including fluoride supplements that you may take.

Medication blanks Taken for blank
Medication blanks Taken for blank
Medication blanks Taken for blank
Medication blanks Taken for blank

Rows	yes	no	dk/u
Emotional, sensory, or developmental issues?
Birth defects or hereditary problems?
Bone fractures, or major injuries?
Any injuries to face, head, or neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment, or chemotherapy?
Stomach ulcer, hyperacidity, or acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, or any other sexually transmitted disease?
AIDS or HIV positive?
Hepatitis, jaundice, or any other liver problems?
Polio, mononucleosis, tuberculosis, or pneumonia?
Seizures, fainting spells, or neurologic problems?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorders (anorexia, bulimia)?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, or swollen ankles?
Heart defects, heart murmur, or rheumatic heart disease?
Angina, arteriosclerosis, stroke, or heart attack?
Skin disorders (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, or throat infections?
Asthma, sinus problems, or hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

Rows	yes	no	dk/u
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)
Penicillin
Other antibiotics
Plant pollens
Animals
Foods

Rows	yes	no	dk/u
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste, or mouth odor?
Jaw fractures, cysts, or 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 the 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 TMJ or TMD problems?
Any broken or missing fillings?
Any serious trouble with previous dental treatment?
Have you been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

Rows	Yes	No	If yes, please explain.
Bleeding Disorders
Diabetes
Arthritis
Severe Allergies
Unusual Dental Problems
Jaw Size Imbalance
Other Family Medical Conditions?

I authorize the release of any information regarding my child's 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 Dental History Form for Patients Under 18

PATIENT

PARENT/GUARDIAN

DENTIST

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

PATIENT HEALTH INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER