The following information is requested to enable us to give you the best consideration of your orthodontic problem during your initial examination in our office. In order to thoroughly diagnose any condition, we must have accurate background and health information on which to base our decisions. Please check the appropriate response where indicated. Thank you.
PHYSICIAN NAME
BUSINESS ADDRESS
PHONE NUMBER
CITY
STATE
ZIP
Presently under physician's care during the past two years other than routine exams?
YES
NO
If YES please specify:
Have you ever taken any oral or I.V. bisphosphonate medications (i.e. Fosamax, Boniva, Actonel, Zometa, Aredia) for the treatment of osteoporosis, bone pain or other conditions?
YES
NO
If YES please specify:
Presently taking any medications?
YES
NO
If YES please list:
Congenital anomalies (birth defects)?
YES
NO
If YES please specify:
Female: Are you pregnant now?
YES
NO
If YES, due date:
Have you had a history of any of the following?
ASTHMA
CARDIOVASCULAR DISEASE
CANCER
HAY FEVER
HEART MURMUR
HERPES
SINUS PROBLEMS
RHEUMATIC FEVER
TUMOR OR GROWTH
RESPIRATORY PROBLEMS
BLOOD DISEASE
SEXUALLY TRANSMITTED DISEASE
TONSILLITIS
BONE DISORDER
EMOTIONAL PROBLEMS
DIZZINESS
AIDS OR HIV POSITIVE
EXCESSIVE BLEEDING
CONVULSIONS
IMMUNE SYSTEM PROBLEMS
FAINTING
EPILEPSY
INFECTIOUS DISEASE
HEPATITIS OR LIVER DISEASE
DIABETES
ARTHRITIS OR PAINFUL JOINTS
ALCOHOLISM
HEARING DISORDER
MIGRAINE HEADACHES
DRUG ABUSE
OTHER
OTHER Conditions not listed:
Comments:
Have you had any serious illness, operation, or been hospitalized within the past 5 years?
YES
NO
If so, what was the illness or problem?
Respiratory History: Do you:
1. Have allergies to:
Seasonal Grasses
YES
NO
Foods
YES
NO
If YES, specify:
Medications
YES
NO
If YES, specify:
Other
YES
NO
If YES, specify:
2. Snore when sleeping?
Seldom
Sometimes
Often
3. Breathe through mouth?
Seldom
Sometimes
Often
4. Have frequent colds?
Seldom
Sometimes
Often
5. Have frequent stuffy nose?
Seldom
Sometimes
Often
6. Have frequent sore throat or tonsillitis?
Seldom
Sometimes
Often
7. Have chewing or swallowing difficulty?
Seldom
Sometimes
Often
8. Have frequent ear infections?
Seldom
Sometimes
Often
Have you recieved medical treatment from an allegist or ear, nose and throat specialist?
YES
NO
If YES, please specify:
WHEN:
BY WHOM:
FOR WHAT CONDITION
Have you had your adenoids removed?
YES
NO
Have you had your tonsils removed?
YES
NO
Have you received or been requested to receive speech correction?
YES
NO
Do you have pain or clicking in the jaw joints?
YES
NO
If YES please specify:
Do you have frequent headaches?
YES
NO
If YES please specify:
Have any teeth been injured due to accidents or blows to the mouth?
YES
NO
If YES please specify:
Please provide information as it pertains to you regarding the following habits:
Thumb sucking until age
Finger sucking until age
Grinding of teeth
YES NO
Tongue thrusting
YES NO
Nail biting
YES NO
Smoking
YES NO
Lip biting or sucking
YES NO
Other:
Have you had any unusual dental experiences?
YES
NO
If YES please specify:
Date of last dental cleaning:
Have you had any previous orthodontic consultations?
YES NO
Or treatment?
YES NO
Date:
Doctor:
Orthodontic consultation prompted by
Patient
Dentist
Physician
Spouse
Friend
Other
Your Interest in orthodontic treatment
Eager
Indifferent
Resigned
Opposed to treatment
What do you feel is the primary problem?
Have any family members been examined or treated in our office?
YES
NO
If YES please specify:
AUTHORIZATION
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I understand that this information will be held in the strictest confidence and it is my responsiblity to inform this office of any changes in my medical status.
SIGNATURE OF PATIENT
DATE
or
If printing form, please remember to bring completed form with you to your first visit.
