In an effort to provide the best service possible, we ask you to fill this form as completely as possible. Thank you for your cooperation!

1. Patient Information

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2. Spouse / Closest Relative

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3. Dentist Information

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4. General Information

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5. Financial Responsibility

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6. Dental Insurance

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7. Medical / Dental History

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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)


MEDICAL HISTORY QUESTIONS: Now or in the past, have you had:

  Birth defects or hereditary problems?
  Bone fractures or major injuries?
  Any injuries to face, head, neck?
  Arthritis or joint problems?
  Endocrine or thyroid problems?
  Diabetes or low 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 other liver problem?
  Polio, mononucleosis, tuberculosis, pneumonia?
  Seizures, fainting spells, neurologic problem?
  Mental health disturbance or depression?
  History of eating disorder (anorexia, bulimia)?
  Excessive bleeding or bruising, anemia?
  Heart defects, heart murmur, rheumatic heart disease?
  Angina, arteriosclerosis, stroke or heart attack?
  Frequent headaches or migraines?
  Asthma, sinus problems, hayfever?
  Tonsilar adenoid condition?

DENTAL HISTORY QUESTIONS: Now or in the past, have you had:

  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, 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 nose?
  Food impaction between the teeth?
  Mouth breathing habit or snoring at night?
  History of gum recession or bone loss?
  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 associate with previous dental treatment?
  Have you ever been diagnosed with gum disease or pyorrhea?

ALLERGY QUESTIONS: Have you had allergies or reactions to any of the following?

  Local anesthetics (novocaine, lidocaine, xylocaine)
  Latex (gloves, balloons)
  Aspirin
  Ibuprofen (Motrin, Advil)
  Penicillin
  Other antibiotics
  Metals (jewelry, clothing snaps)
  Acrylics
  Other substances

8. Patient Health Information

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List any medication, nutritional supplements, herbal medications, and/or non-prescription medicines, including fluoride supplements that you take:

9. Family Medical History

Section 9 of 10

Have the parents or siblings ever had any of the following health problems? If so, please explain:

10. Release & Waiver Signature

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I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidences and it is my responsibility to inform this once of any changes in my medical status. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the once. I understand that where appropriate, credit bureau reports may be obtained.

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 medical or dental health.

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