Medical History
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1MEDICAL HISTORY
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Patient Name
For the patient named on this form: Place a check in the “ yes” (Y) column for each condition which is
currently or has ever been applicable. Otherwise place a check in the “ no” (N ) column.
Y
N
Y
N
Previous orthodontic treatment
Frequent shortness of breath
Dental problems other than routine care
Sinus trouble
Tooth extractions (removal)
Smoker or smokeless tobacco
Negative reaction to dental care
Seasonal allergy
Injury to face or mouth
Allergy to medication
Jaw pain
Hives or rash
Difficulty moving jaw
Other allergy
Difficulty chewing
Mumps
Difficulty swallowing
Chickenpox
Gag easily
Venereal disease
Suck your thumb or fingers
Fainting or dizziness
Play a musical instrument
Thyroid or other endocrine disorder
Tonsils or adenoids removed
Frequent headaches
Speech impairment
Epilepsy or seizures
Heart condition
Emotional or nervous disorder
Congenital heart defect
Psychiatric care
Rheumatic fever
Severe weight loss or gain
Chest pains
Diabetes
Swollen ankles
Kidney or liver disease
Stroke
Ulcers
Bleeding problems
Scarlet fever
High or low blood pressure
Ear pain or infection
Anemia
Hearing impairment
Artificial valves or joints
Glaucoma
Blood transfusion
Arthritis
Compromised immune system
Cancer or tumor
HIV or AIDS
Major surgery
Lung Disease
Birth defects
Asthma
Other recurrent illness
Bronchitis
Taking any medications or supplements
Emphysema
FEMALES ONLY:
Pneumonia
Reached menses (first period)
Tuberculosis
In menopause
Frequent colds or sore throat
Using birth control medication
Persistent cough
Pregnant
HISTORY GIVEN BY: ___________________________________________ DATE: _____________
Doctor’s Notes:
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Medical alerts to be entered in e-chart? □ Y □ N ________________________________
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Parent category: Medical