Dental History & Status

Have you ever had: Yes | No ●  Any injured or broken teeth?     ●  Any unusual reaction to dental medications?     ●  Any injuries to your head or face?     ●  Any problems with eating, chewing or swallowing?     ●  Any dental or facial pain?     ●  Any jaw joint noise or pain when opening, closing or chewing?     ●  A tooth clenching or grinding habit?     ●  Soreness in the muscles of your face?     ●  Difficulty breathing with your mouth closed?     ●  Swellings or growths in your mouth?     ●  Gums that bleed when brushing your teeth?     ●  Treatment from a periodontist, endodontist or oral surgeon?             When:     Whom: ●  Previous orthodontic treatment or consultation?             When:     Whom: ●  Are you dissatisfied about the appearance of your teeth? ●  Are you especially concerned about orthodontic treatment? ●  Is there other information we should know?

Medical History

Yes | No ●  Are you presently in good health?         Date of last physical exam: ●  Are you being treated by a physician?         For what? ●  Have you been hospitalized or had a major illness in the last 5 years?         Please explain: ●  Are you taking any prescription or non-prescription medications, or nutritional supplements?         Please list: ●  Do you have any allergies to drugs or medicines?         Please list: ●  Are there any congenital problems?         Please list: ●  Do you drink alcohol?         If yes, how often? ●  Do you use tobacco?         If yes, how much and what form? ●  Have you had recurrent sores in your mouth or on other parts of your body?     ●  Did you ever have a drug transfusion, particularly prior to March 1985?     ●  For women: Are you pregnant or anticipating pregnancy?         If yes, give due date: ●  Are you taking hormonal supplements?     Have you ever been diagnosed or treated for the following? Yes No ●  AIDS or HIV Positive?     ●  Anemia     ●  Arthritis     ●  Bone disease     ●  Breathing problems     ●  Cancer or been treated for tumor     ●  Cerebral palsy     ●  Diabetes     ●  Dizziness/fainting spells     ●  Emotional problems     ●  Epilepsy or neurologic problems     ●  Glaucoma     ●  Heart disorder or defects     ●  Hepatitis             If yes, hepatitis type: ●  Kidney problems     ●  Hearing, tasting, speech difficulties     ●  Immune system problems     ●  Substance abuse problems     ●  Liver problems     ●  High or Low blood pressure     ●  Multiple sclerosis     ●  Prolonged bleeding     ●  Respiratory allergies     ●  Rheumatic fever     ●  Scarlet fever     ●  Shortness of breath     ●  Sickle cell anemia     ●  Sinus problems     ●  Stomach ulcers     ●  Stroke     ●  Thyroid or endocrine problem     ●  Tuberculosis     ●  Other, please specify: ●  Is there any other information concerning your health the doctors should be aware of?

Employee/Subscriber Information (if you have orthodontic insurance)

Employee subscriber name:    SS# Employed by:    Subscriber date of birth: Subscriber's relationship to patient: Ortho insurance company name:    Group # Insurance company phone #

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