Medical History

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Please complete if patient is a minor:
Parent’s or Guardian’s Name______________________________________________________________________________________________
Address (if different from patient) ________________________________________ Home Phone (if different from patient) ________________
Day time phone number_________________________________ E-Mail Address___________________________________________________
Father Employed by_________________________________________ No. of years___________ Position_______________________________
Mother Employed by________________________________________ No. of years___________ Position_______________________________
Do you have orthodontic insurance benefits?
YES
NO
Who will be financially responsible for the orthodontic treatment? ________________________________________________________________
If divorce is involved, who is the custodial parent? ________________ May patient information be released to the non-custodial parent? _______
Patient Information:
Patient’s Name___________________________________________ Birth Date_____________________________________________________
School (if student) _________________________________Grade________________________________________________________________
Names and ages of siblings_______________________________________________________________________________________________
Employed by______________________________________________ No. of years___________ Position_______________________________
Office Financial Flexibility:
To qualify for our most flexible in office financing, please complete the following information:
Responsible Party______________________________________________________________
Social Security Number____________________________________DOB_________________
I understand a credit check may be done. This will have no effect on future credit ratings.
SIGNATURE___________________________________ DATE________________
MEDICAL HISTORY
YES
NO
1) Are you now under a physician’s care?
For what reason?
2) Do you pre-medicate with antibiotics for dental visits?
3) Are you currently taking any medications? What?
4) Have you ever been diagnoses with osteoporosis, osteopenia, or bone cancer?
If so, what medications have been taken?
5) Allergies: latex, food, pollen, drugs, metals, plastics, etc.
6) Any congenital or acquired physical or mental disabilities? What
7) Review of systems – any problems with: head, eyes, ears, nose, throat, heart, lungs, stomach-gut, glands/endocrine, bones,
skin, nerves, personality
8) Illnesses (circle): rheumatic fever, mumps, measles, chicken pox, diphtheria, scarlet fever, blood pressure/heart disease,
herpes, tonsillitis, hepatitis, VD, HIV/AIDS, influenza, cancer, diabetes, blood problems, TB, epilepsy, rubella.
9) Any history of chronic headaches or pain around ears
10) Any problems with nasal breathing or tonsils and adenoids?
11) Any other information?
The information that I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to
inform this office of any changes in my/my child’s medical status. I authorize the dental staff to perform any necessary dental services that I or my child may need during diagnosis
and treatment with my informed consent. I have also received a copy of the office’s notice of privacy practices.
Signature___________________________ Date ________

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