General Information

Patient’s Name:

Date of Birth:

Age: Sex: Male  Female

Address:
City:
Postal Code:

Home Phone:
Cell:

Parent / Guardian:
Business Phone:

Parent / Guardian:
Business Phone:

Name of other family members treated by our office:

How did you hear about our office:

Dentist’s Name: Physician’s Name:

Medical History

1. Is the patient in good general health? Yes  No
2. Is the patient under the care of a physician for any medical concern? Yes  No
3. Is the patient taking any medications or drugs at the present time? Yes  No
4. Has the patient ever had any serious illness, operation, or been hospitalized? Yes  No
5. Does the patient have or ever had any of the following?
asthma
blood disorders
joint replacement
liver disease
ulcers/stomach problems
steroid therapy
lung disease
anemia
heart attack
hepatitis
epilepsy or seizures
AIDS or HIV
allergies
rheumatic fever
stroke
jaundice
cancer
diabetes
hay fever
heart murmur
high/low blood pressure
kidney disease
arthritis/rheumatism
thyroid disease
sinus problems
congenital heart defect
gastrointestinal problems
immune disorders
6. Has the patient ever experienced any unusual reactions to any of the following?
aspirin
local anesthetics
sulfonamides
codeine
other antibiotics
latex
penicillin
nickel or other metal
other:




7. For female patients: Is there a chance you may be pregnant? Yes  No
8. Has the patient ever had any medical radiation therapy? Yes  No
9. Is there anything else that the orthodontist should know regarding the medical history? Yes  No
10. Has the patient had their tonsils or adenoids removed? Yes  No
11. Has the patient ever had a severe accident involving their teeth or jaws? Yes  No

Dental and Orthodontic History

1. Is the patient aware or concerned about their orthodontic problem? Yes  No
2. Is the patient interested in having their orthodontic problem treated? Yes  No
3. Has the patient ever been teased about the appearance of their teeth? Yes  No
4. Does the patient have any difficulty chewing or swallowing? Yes  No
5. Does the patient suffer from any jaw joint problems? Yes  No
6. Is there a history in your family of irregular teeth? Yes  No
7. Is there a history in your family of protruding teeth? Yes  No
8. Is there a history in your family of congenitally missing teeth? Yes  No
9. Is there a history of trauma to the teeth or jaws? Yes  No
10. Does any other family member have similar appearance of their jaws? Yes  No
11. Does any other family member have a similar arrangement of teeth? Yes  No
12. Does the patient breath through their mouth? Yes  No
13. Does the patient play any wind instruments? Yes  No
14. Does the patient have or ever had habits like thumbsucking, lipsucking, lip biting, or other habits? Yes  No
15. Has the patient had a sudden increase in height? Yes  No
16. Has the patient seen an orthodontist previously? Yes  No
17. Has the patient had any previous orthodontic treatment? Yes  No
18. Has any other member of the family had orthodontic treatment? Yes  No
19. Briefly describe the main concerns the patient has with their teeth and/or jaws?

Consent:

I have provided the above dental and medical information, reviewed it and find it accurate. If there are any changes to this history record, I will so inform this practice. I also give my authorization for an orthodontic examination to be performed. I authorize Dr. Darryl Smith to use and disclose information contained in my dental records to my dentist, family physician and other dental / medical specialist and to my insurance company and its agents / contractors with respect to myself (and / or my children’s orthodontic treatment). This information could include (but is not limited to) things such as name, address, phone number, gender, date of birth, insurance information, employer, health and / or dental records. I understand that this information is collected to provide me and my family with safe and efficient care. I also understand that this office endeavors to ensure that personal information is accurate, up to date and protected. I also acknowledge, where applicable, that it is my responsibility to inform you of any changes in my / my child’s medical status. I further acknowledge that, during the course of treatment, you will continue to discuss treatment details regarding my child with the responsible party UNLESS we choose to notify you otherwise, in writing, when my child turns 18.

 I have read the consent agreement and agree.