MEDICAL DENTAL HISTORY FORM

CONFIDENTIAL
(Please fill out the form completely)
Last Name
 First Name
Physician Name:
 Phone #:
( ) -
Date last seen:
/ / 		Reason:
Medical Insurance Company:
 Enrollee I.D. #:
For the following questions mark Yes, No, or Don't Know/Understand (dk/u). The answers are for office records only and are confidential. A complete history is vital to an orthodontic evaluation.
MEDICAL HISTORY
Now or in the past, have you had:
Yes No Dk/u Birth defects or hereditary problems?
Yes No Dk/u Bone fractures, any major accidents?
Yes No Dk/u Rheumatoid or arthritic conditions?
Yes No Dk/u Endocrine or thyroid problems?
Yes No Dk/u Kidney problems?
Yes No Dk/u Diatetes?
Yes No Dk/u Cancer, tumor, radiation treatment or chemotherapy?
Yes No Dk/u Stomach ulcer or hyperacidity?
Yes No Dk/u Polio, mononuleosis, tuberculosis, pneumonia?
Yes No Dk/u Problems of the immune system?
Yes No Dk/u AIDS or HIV positive?
Yes No Dk/u Hepatitis, jaundice or liver problem?
Yes No Dk/u Fainting, spells, seizures, epilepsy or neurological problem?
Yes No Dk/u Mental health disturbance or drepression?
Yes No Dk/u Vision, hearing, tasting or speech difficulties?
Yes No Dk/u Loss of weight recently, poor appetite?
Yes No Dk/u History of eating disorder (anorexia, bulimia)?
Yes No Dk/u Excessive bleeding or bruising tendency, anemia or bleeding disorder?
Yes No Dk/u High or low blood pressure?
Yes No Dk/u Tired easily?
Yes No Dk/u Chest pain, shortness of breath or swelling ankles?
Yes No Dk/u Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)?
Yes No Dk/u Skin disorder?
Yes No Dk/u Do you have a well-balanced diet?
Yes No Dk/u Frequent headaches, colds or sore throats?
Yes No Dk/u Eye, ear, nose or throat condition?
Yes No Dk/u Hay fever, asthma, sinus trouble or hives?
Yes No Dk/u Tonsil or adenoid conditions?
Yes No Dk/u Osteoporosis?
Yes No Dk/u Sleep Apnea? (Stop breathing when sleeping)

Allergies or reactions to any of the following:
Yes No Dk/u Local anesthetics (Novacaine or Lidocaine)
Yes No Dk/u Aspirin
Yes No Dk/u Ibuprofen (Motrin, Advil)
Yes No Dk/u Penicillin or other antibiotics
Yes No Dk/u Sulfa drugs
Yes No Dk/u Codeine or other narcotics
Yes No Dk/u Metals (jewelry, clothing snaps)
Yes No Dk/u Latex (gloves, balloons)
Yes No Dk/u Vinyl
Yes No Dk/u Acrylic
Yes No Dk/u Animals
Yes No Dk/u Foods (specify):
Yes No Dk/u Other substances (specify):
Yes No Dk/u Are you taking medication, nutrient supplements, herbal medications or non prescription medicine?
Please name them.
Medication: Taken for:
Medication: Taken for:
Medication: Taken for:
Medication: Taken for:
Medication: Taken for:
Medication: Taken for:
Medication: Taken for:
Yes No Dk/u Do you currently have or ever had a substance abuse problem?
Yes No Dk/u Do you chew or smoke tobacco?
Yes No Dk/u Operations?
Describe:
Yes No Dk/u Hospitalized?
Describe:
Yes No Dk/u Other physical problems or symptoms?
Describe:
Yes No Dk/u Being treated by another health care professional?
For:
Date of most recent physical exam?
/ /
Do you have any other medical conditions that we should know about?

For Women Only:
Yes No Dk/u Are you pregnant?
Yes No Dk/u Are you anticipating becoming pregnant?

FAMILY MEDICAL HISTORY:
Do your parents or siblings have, or have ever had any of the following health problems? If so, explain.
Bleeding Disorders:
Diabetes:
Arthritis:
Severe Allergies:
Unusual Dental Problems:
Jaw Size Imbalance:
Any other family medical conditions that we should know about?

DENTAL HISTORY
Now or in the past, have you ever had:
Yes No Dk/u Permanent or "extra" (supernumerary) teth removed?
Yes No Dk/u Supernumerary (stra) or congenitally missing teeth?
Yes No Dk/u Chipped or otherwise injured primary (baby) or permanent teeth?
Yes No Dk/u Teeth sensitive to hot or cold; teeth throb or ache?
Yes No Dk/u Jaw fractures, cysts or mouth infections?
Yes No Dk/u Dead teeth or root canals treated?
Yes No Dk/u Bleeding gums, bad taste or mouth odor?
Yes No Dk/u Periodontal "gum problems"?
Yes No Dk/u Food impaction between teeth?
Yes No Dk/u "Gum boils", frequent canker sores or cold sores?
Yes No Dk/u Thumb, finger, or sucking habit? Until what age?
Yes No Dk/u Abnormal swallowing habit (tongue thrusting)?
Yes No Dk/u Mouth breathing habit, snoring or difficulty in breathing?
Yes No Dk/u Tooth grinding or jaw clenching?
Yes No Dk/u Any pain, clicking or locking in jaw or ringing in ears?
Yes No Dk/u Any pain or soreness in the muscles of the face or around the ears?
Yes No Dk/u Difficulty in chewing or jaw opening?
Yes No Dk/u Have you ever been treated for "TMD" or "TMJ" problems?
Yes No Dk/u Aware of loose, broken or missing restorations (fillings)?
Yes No Dk/u Any teeth irritating cheek, lip, tongue or palate?
Yes No Dk/u Concerned about spaced, crooked or protruding teeth?
Yes No Dk/u Aware or concerned about under or over developed jaw?
Yes No Dk/u Any relative with similar tooth or jaw relationships?
Yes No Dk/u Any wisdom tooth problems?
Yes No Dk/u Had periodontal (gum) treatment?
Yes No Dk/u Had any serious trouble associated with any previous dental treatment?
Yes No Dk/u Been under another dentist's care?
Specialist
Other
Yes No Dk/u Ever had a prior orthodontic examination or treatment?
Yes No Dk/u Would you object to wearing orthodontic appliances (braces) should they be indicated?

How often do you brush?
How often do you floss?

I have read and understand

Chief concern and what would you like to see change: