Patient And Responsible Party Information Page 2
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3Does responsible party have Orthodontic Insurance? Yes No
MEDICAL HISTORY:
Excellent
Good
Fair
Poor
Patient’s general health:
Last complete physical:
Date ___/___/___
Has patient had or does patient have any of the following?
Yes
No
Yes
No
Rheumatic Fever
Persistent Headaches
Heart Murmur
Neck Pains
High Blood Pressure
Nerve or Brain Disease
Heart Attack/Stroke
Migraine
Blood Vessel Disease
Epilepsy
Blood Disorder
Mental Health Problems
AIDS/HIV Infection
Bone Disorders
Hepatitis
Arthritis (any type)
Diabetes
Sleep Apnea
Ulcers
Ear Disorder
Herpes (any type)
Sinus Infection
Psoriasis
Swollen Glands
Cancer
Allergies
Comments
Please list any other significant information about the patient’s medical history:
Yes
No
Is patient under a physician’s care at present? If yes, reason
Is patient presently, or has patient ever been under the care of a psychiatrist or
psychologist? If yes, describe
Is patient currently taking any medication? If yes, describe
Is the patient allergic to any medications? (Ex.: aspirin, penicillin, etc.) If yes, what?
Has patient ever had any general anesthesia? When?
Does patient need to Pre-Medicate?
Please describe why you sought this consultation________________________________________________
Has patient ever been treated for this problem before? If yes, please describe the diagnosis and treatment
__________________________________
DENTAL HISTORY
Last dental check-up:
Dr.
Date _____/_____/______
Bleeding Yes No
How often are the teeth brushed daily:
Flossed
Yes
No
Does the patient gag easily?
Do any of your teeth hurt? If yes, upper right upper left lower left lower left
Have any wisdom teeth been removed? How many?
Have you ever had treatment for a periodontal disease (gum disease)? If yes, when
Have you ever had any previous orthodontic treatment (braces)? If yes, when
If yes, doctor’s name and address
Have there been any injuries to your mouth or teeth? If yes, describe
Have you ever been any injury in the head and neck area? If yes, describe
Have you ever fallen and bumped your chin, or received a blow to your jaws? If yes,
describe
Have you ever had any surgery in the head and neck area? If yes, describe
Do you clench or grind your teeth? If yes, while sleeping r under stress r other_______
Do your jaw muscles ever feel tired? If yes, when
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