New Patient Information Form Page 2

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Medical History
Physician _________________________________________________ Date of Last Visit _____________________________
Address __________________________________________________ Phone _____________________________________
Please circle Yes or No (If Yes, please fill in details)
Yes
No
Are you taking any medication? ____________________________________________________________
Yes
No
Are you allergic to any medication? _________________________________________________________
Yes
No
Do you have a history of a major illness? _____________________________________________________
Yes
No
Have you had any operations? _____________________________________________________________
Yes
No
Have you ever been involved in a serious accident? ____________________________________________
Yes
No
Have seen a physician in the last 12 months? Why? ____________________________________________
Circle any of the medical conditions below that you have had or currently have.
Abnormal bleeding/Hemophilia
Diabetes
Hepatitis/Liver problems
Pneumonia
Anemia
Dizziness
Herpes
Prolonged Bleeding
Arthritis
Epilepsy
High Blood Pressure
Radiation/Chemotherapy
Asthma or Hayfever
Gastrointestinal Disorders
HIV / Aids
Rheumatic Fever
Bone Disorders
Heart Problems
Kidney problems
Tuberculosis
Congenital Heart Defect
Heart Murmur
Nervous Disorders
Tumor or Cancer
Are there any medical conditions we have not discussed that you feel we should be aware of? _________________________
___________________________________________________________________________________________________
Dental History
General Dentist ____________________________________________ Date of last visit ______________________________
What concerns you most about your teeth? _________________________________________________________________
Yes
No
Are you presently in any dental pain? ________________________________________________________
Yes
No
Have you ever experienced any unfavorable reaction to dentistry? _________________________________
Yes
No
Have you ever lost or chipped any teeth? _____________________________________________________
Yes
No
Have there been any injuries to face, mouth, or teeth? __________________________________________
Yes
No
Is any part of your mouth sensitive to temperature? Where? ______________________________________
Yes
No
Is any part of your mouth sensitive to pressure? Where? _________________________________________
Yes
No
Do your gums bleed when you brush? _______________________________________________________
Yes
No
Do you have any type of thumb or tongue habit? _______________________________________________
Yes
No
Are you a mouth breather? ________________________________________________________________
Yes
No
Have you ever seen an orthodontist? If yes, who and when? ______________________________________
Yes
No
What is your attitude toward receiving orthodontic treatment? _____________________________________
Yes
No
Has anyone in your family received orthodontic treatment? _______________________________________
How did they feel about the result? __________________________________________________________
Yes
No
Do your teeth or jaws ever feel uncomfortable when you awake in the morning? ______________________
Yes
No
Are you aware of your jaw clicking or popping? ________________________________________________
Yes
No
Are you aware of clenching your teeth during the day? __________________________________________
Yes
No
Have you ever been told that you grind your teeth? _____________________________________________
Yes
No
Do you have “tension” headaches? _________________________________________________________
Yes
No
Have you ever experienced chronic ringing in your ears? ________________________________________
Yes
No
If the patient is under age 16, height of parents? Mom______ Dad______
Yes
No
Are you aware that some appointments will be during school/work hours? ___________________________
Please list some hobbies or interests ________________________________________________________
Female Patients only:
Yes
No
Are you pregnant? ______________________________________________________________________
Yes
No
Has menstruation started? ________________________________________________________________
Signature: __________________________________________________________________ Date: ____________________

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