Welcome to Our Office!

Birthdate: Age:

Name: Prefer to be called:

Home Residence:

Phone (H): Phone (C):

Whom may we thank for referring you?

Do you know any patients in our practice? Yes No        Who?

Please describe the orthodontic problem in your own words.

Have you had any previous orthodontic consultation? Yes  No  With whom?

Have you had any previous orthodontic treatment? Yes  No  Explain:

Dental History

Patient's Dentist: Location:

Frequency of dental checkups: Twice/year Once/year As needed Never Date of last Visit:

Is there any unfinished care to be completed by your dentist? Yes  No Explain:

Are you uncomfortable about dental treatment? Explain:

Do you have a history of: Injuries to head, neck or jaws Yes No Clenching/grinding teeth Yes No Muscular soreness around head & neck Yes No Jaw joint soreness Yes No Jaw joint clicking/popping Yes No Ringing in the ears Yes No Mouthbreathing Yes No Awake

Do you have a history of tongue thrust? Yes  No Seeing/seen a speech therapist? Yes  No

Do you have a parafunctional habit? (chewing on pens, barrettes, etc.) Explain:

Is there any information that may be helpful? Explain:

Medical History

Physician's Name: Phone:

Have you experienced any health problems? Yes  No Explain: Any major change in your health? Yes  No Explain: Are you currently under a physician's care? Yes  No Explain: Are you currently taking medications? Yes  No Which?: Are you allergic to or made sick by any medications including penicilin, aspirin, codeine? Yes  No What? Are you allergic to latex, avocados, strawberries, nuts or anything foods/materials not listed? Yes  No What?

Do you take medicine prior to dental treatment? Yes  No Which? Dosage?

Have you had your tonsils and/or adenoids removed? Yes  No Which? Why?

Women: Are you pregnant? Yes  No Anticipating becoming pregnant in the next 2 years? Yes  No Are you practicing birth control? Yes  No

Check any of the following which you have had or have at present:

Heart Failure Emphysema HIV/AIDS Heart Disease or Attack Bronchitis/Cough Hepatitis A/B/C/D/E Angina Pectoris Tuberculosis (TB) Bruise Easily High Blood Pressure Asthma Blood Transfusion Heart Murmur Hay Fever/Asthma Drug Addiction Mitral Valve Prolapse Sinus Trouble Hemophilia Rheumatic Fever Allergies or Hives Developmental Disorder Congenital Heart Lesions Diabetes Cold Sores Scarlet Fever Thyroid Disorder Epilepsy/Seizures Artificial Heart Valve/Joint X-ray/Colbalt Treatment Fainting/Dizziness Heart Pacemaker Endocrine Disorders Nervousness Heart Surgery Arthritis Psychiatric Treatment Anemia Rheumatism Sickle Cell Disease Stroke Cortisone Medicine Ulcers Kidney Trouble Glaucoma Growth Disorder Chemotherapy (Cancer/Leukemia) Liver Disease/Yellow Jaundice Venereal Disease (Herpes/Syphilis/Gonorrhea) Is there any condition not listed that we should know about?  Comments:

Medical History/Physical Evaluation Update

Date:  Addition:

Date:  Addition:

Date:  Addition:

To the best of my knowledge, all of the preceding information is true and correct. If there is ever any change in my health status, or if medications change, I will inform the doctor at the next appointment without fail. Date: _____________________ Signature _______________________________________________ Signature will be obtained at your visit to our office.