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Patient Information

























YesNoHas the patient received previous orthodontic consultation?

YesNoDo you have any other family members in our practice?
Dental History













Medical History













Insurance Information
Primary Insurance













Secondary Insurance












Medical History(continued)
YesNoAre you having dental pain or discomfort?
YesNoAre you currently under physicians care?
YesNoAre taking any medications?
YesNoAre allergic to any medications, food, latex?
YesNoDo you take any medications prior to dental treatment?
YesNoHave you ever had any excessive bleeding requiring special treatment?
YesNoHave you ever had any trauma
YesNoHas anyone in your family had orthodontic treatment that has caused root resorption?
YesNoWhen you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or becuase you are very tired?
YesNoDo your ankles swell during the day?
YesNoDo you have any disease, condition, or problem not listed?
Women:
YesNoAre you pregnant now?
YesNoDo you anticipate becoming pregnant?
YesNoDo you breath through your mouth?
YesNoDo you snore when you are asleep?
YesNoDo you sleep with your mouth open?
YesNoDo you have sleep apnea?
YesNoDo you sleep with a CPAP?
Check any of the following which you have had or have at present:
Heart Failure
Emphysema
Aids
Heart Disease or Attack
Cough
HIV Positive
Angina Pectoris
Tuberculosis (TB)
Hepatitis A (infectious)
High Blood Pressure
Asthma
Hepatitis B (serum)
Heart Murmur
Hay Fever
Liver Disease
Heart Pacemaker
Sinus Trouble
Rheumatic Fever
Heart Surgery
Blood Transfusion
Drug Addiction
Congenital Heart Lesions
Diabetes
Hemophilia
Mitral Valve Prolapse
Thyroid Disease
Cold Sores
Venereal Disease (Syphilis, Gonorrhea)
Artificial Heart Valve
X-Ray or Cobalt Treatment
Allergies or Hives
Cancer/Tumor
Chemotherapy
Arthritis
Genital Herpes
Artificial Joint
Rheumatism
Epilepsy or Seizures
Anemia
Cortisone Medicine
Fainting or Dizzy Spells
Stoke
Glaucoma
Nervousness
Kidney Trouble
Pain in Jaw Joints
Psychiatric Treatment
Ulcers
Bruise Easily
Sickle Cell Disease
Scarlet Fever

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or change in medications, I will inform the office and doctor at the next appointment without fail.


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