patient forms

Please take a minute to print and fill out the patient information form before your first appointment:

CHILD MEDICAL HISTORY FORM

ADULT MEDICAL HISTORY FORM

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MEDICAL HISTORY FORM
FOR PATIENTS UNDER 18 YEARS OF AGE

Gender

MaleFemale

Onset of puberty?

yesno

Parent is:

SingleMarriedSeparatedDivorcedRemarriedWidowed

PLEASE CHECK ANY THAT APPLY:

Medical History


Allergies or asthmaAllergies to latex / metalsHeart MurmurHeart ProblemsRheumatic feverBlood disordersHepatitisLiver or kidney disordersDiabetesCancerNail or lip bitingAIDS antibody positiveSTD’sTonsils removedSpeech problemsMouth breathingPrevious orthodontic care

Dental History


Missing or extra teethGrinding of teethJaw painEarly loss of baby teethThumb or finger suckingTrauma to face or teethNail or lip bitingThumb or finger sucking

Does your child regularly receive any medicine and/or medical treatment?


yesno

Has your child ever had an unfavorable reaction to any drugs, antibiotics, or anesthetics?


yesno

Because your child is a minor, it is necessary that a signed permission be obtained from a parent or guardian before any orthodontic services can be started. I have read and understand the above questions. The information provided is accurate to the best of my knowledge. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. It is my responsibility to notify this practice if there are any changes later to this history record or medical/dental status.


Thank you for your cooperation. The above information is important in your child’s diagnosis and treatment, and will be kept confidential.

Office use: Medical/dental information above reviewed with patient.