Medical History Form printable pdf download

Medical History Form

Name:________________________________

Do you have, or have you ever had, any of the following medical conditions (circle if yes):

Heart problems; Heart Murmur; Blood pressure problem; Asthma/breathing problem;

Allergies; Diabetes/Endocrine problem; Immune system problem; Bleeding disorder;

Anemia; Arthritis; Liver problem/hepatitis; Neurological/Mood disorder

Details about circled conditions

______________________________________________________________________________

Are you currently taking any medications (Please list)___________________________________

______________________________________________________________________________

Do you have, or have you ever had, any of the following dental conditions (circle if yes):

Cavities; Gum disease/periodontal disease; TMJ problems (clicking or pain in your jaw

joints); Teeth sensitive to hot/cold; Teeth extracted; Wisdom teeth problems; Speech

problems; Abnormal swallowing; Sucking habit (thumb sucking, nail biting, etc.); Dead

teeth/root canal treatments; jaw fractures

Details about circled conditions_____________________________________________________

______________________________________________________________________________

How often do you brush: ______________________ Floss: _____________________________

What is your primary concern? Why are you here?

______________________________________________________________________________

I have read and I understand the above questions. I will not hold my orthodontist or any member

or his/her staff responsible for any errors or omissions that I have made in the completion of this

form. If there are any changes later to this history record or medical/dental status, I will so

inform this practice.

Signed Patient:_________________________________________________

Date:_________________________________________________________

Medical History Form