wbortho.com-NEW-PATIENT-MEDICAL-FORM

Medical-Dental History

Patient’s Name *

Patient’s Email *

Today’s Date *

Month Day Year

1. Are you currently under the care of a physician for an existing condition?

Yes No

If yes, please explain:

2. Are you taking any prescription or over-the-counter medications?

Yes No

If yes, please explain:

3. Do you have any allergies?

Yes No

4. Have you been hospitalized within the past year for any reason?

Yes No

If yes, please explain:

5. Do you have or have you had any of the following conditions?

Arthritis

Yes No

Asthma

Yes No

Congenital Heart Defect

Yes No

Diabetes

Yes No

Heart Murmur

Yes No

Hepatitis

Yes No

Rheumatic Fever

Yes No

Severe/Frequent Headaches

Yes No

6. Has antibiotic pre-medication ever been required for dental treatment?

Yes No

If yes, please explain:

7. Have you ever had any injuries to the face, mouth or teeth?

Yes No

If yes, please describe

8. Have you been informed of any missing or extra permanent teeth?

Yes No

9. Do any of the following conditions exist?

Clenching or Grinding of Teeth

Yes No

Finger or thumb sucking

Yes No

Speech Problems

Yes No

E-Signature

Thank you for completing this form. It will enable us to care for you in a more effective manner.