Patient Information Form For Patients Under 18 Years Of Age Form Page 2
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1
2MEDICAL HISTORY
Physician_________________________________________________ Date of Last Visit _____________________________
Address __________________________________________________ Phone _____________________________________
Please circle Yes or No (If Yes, please fill in details)
Yes
No
Is the patient taking any medication? ________________________________________________________
Yes
No
Is the patient allergic to any medication? _____________________________________________________
Yes
No
History of a major illness? _________________________________________________________________
Yes
No
Has the patient had any operations? _________________________________________________________
Yes
No
Ever been involved in a serious accident?_____________________________________________________
Yes
No
Have seen a physician in the last 12 months? Why? ____________________________________________
Female Patients only:
Yes
No
Has menstruation started? _________________________________________________________________
Yes
No
Is the patient pregnant? ___________________________________________________________________
Circle any of the medical conditions below that the patient has had or currently has.
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
Is the patient presently in any dental pain? ____________________________________________________
Yes
No
Ever experienced any unfavorable reaction to dentistry? _________________________________________
Yes
No
Has the patient 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 gums bleed when brushing?_____________________________________________________________
Yes
No
Any type of thumb or tongue habit? _________________________________________________________
Yes
No
Is the patient a mouth breather? ____________________________________________________________
Yes
No
Has the patient ever seen an orthodontist? If yes, who and when? _________________________________
Yes
No
What is the patient’s attitude toward receiving orthodontic treatment? _______________________________
Yes
No
Has anyone in the family received orthodontic treatment? ________________________________________
How did they feel about the result? __________________________________________________________
Yes
No
Do teeth or jaws ever feel uncomfortable first thing in the morning? _________________________________
Yes
No
Experience jaw clicking or popping? _________________________________________________________
Yes
No
Aware of clenching or grinding teeth during the day? ____________________________________________
Yes
No
Experience “tension” headaches? ___________________________________________________________
Yes
No
Has the patient ever experienced chronic ringing in the ears? _____________________________________
Yes
No
Does the patient need extra help with instructions? _____________________________________________
Yes
No
Is the patient sensitive or self-conscious about his/her teeth?______________________________________
Yes
No
Height of parents? Mom______ Dad______
Yes
No
Are you aware that some appointments will be during school hours?________________________________
BENEFITS
Benefits of Orthodontics: Aesthetics, Health, and Function. Orthodontics is a service that provides an improvement in the
appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate
body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result.
Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime and
there can be some movement of teeth and some change after treatment. I have read and understand this paragraph. I also
understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully
answered all the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I
authorize Dr. ____________________ to perform a complete orthodontic evaluation.
Signature: _____________________________________________Date: ____________________
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Parent category: Medical