Medical Form

Basic Information
Name*
First Last
Sex*
Address*
Street Address Address Line 2 City Postal Code
Home Phone*
Work Phone
Email*
Date of Birth*
In an emergency, contact:*
Name of your dentist
Person who referred you
Reason for your visit
Medical History
Are you currently followed by a doctor?
Name of doctor, and phone number:
Do you currently take medication or in the last six months?
Please list all medications:*
Are you pregnant?
Have you ever suffered or are you suffering from...
Cardiac disorders (myocardial infarction, angina, valve problems, breathing problems)?
Rheumatic fever?
Prolonged bleeding?
Anemia ?
Blood pressure?
Frequent colds or sinusitis?
Tuberculosis or lung problems?
Stomach problems, digestive disorders?
Liver problems (hepatitis A, B, C, cirrhosis)?
Kidney problems?
Diabetes?
Thyroid problems?
Skin diseases?
Eye Problems?
Arthritis?
Epilepsy?
Frequent headaches?
Dizziness, fainting?
Earache?
Asthma?
Sleep apnea?
Are you a smoker?
Have you ever had radiation treatment or chemotherapy?
Do you have artificial joints?
Do you have any allergies to food or medications?
Please specify your allergies:*
Do you have an allergy to latex or any metal?
Have you ever been hospitalized or undergone surgery other than dental?
Which hospital and when?*
Comments
Dental History
Last dental visit*
Treatments received
Do you have pain in the mouth or joints?
Have any permanent teeth been removed?
Have any permanent teeth been injured or chipped by an accident?
Do you have any head or face injuries?
Do you have any speech problems?
Have you ever sucked a thumb or fingers?
Until what age?*
Do you breathe predominantly by the mouth?
Do you have tongue thrust?
Do you grind or clench teeth?
Do you play a wind instrument?
Have you seen another orthodontist?
Do you have any recent radiographs? (x-rays)
Do you have any clicking, cracking or pain in jaw?
Have you ever had the following dental treatment or services...
Demonstration of oral hygiene?
Gum treatment?
Orthodontic treatment (braces)?
Root canal?
Dental surgery or extraction?
Dental implants?

Medical Form

Medical Form

Basic Information

Medical History

Have you ever suffered or are you suffering from...

Dental History

Have you ever had the following dental treatment or services...