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Date: CONFIDENTIAL

American Association of Orthodontists MEDICAL DENTAL HISTORY FORM FOR PATIENTS UNDER 18 YEARS OF AGE
Patient's Last Name: Birth Date: S.S.N./S.I.N.: Age: First Name: Sex: Male Female Middle Name/Initial: Prefers To Be Called: _________________________________________ Home Phone No.: ( ) -

Patient's Address: __________________________________________________________________________________________________________________ City: Attends School At: Grade: State/Province: Musical Instruments Played: Zip/Postal Code:

Sports And/Or Hobbies: _____________________________________________________________________________________________________________ No. of brothers and sisters: Ages: ________________________________

Other family members treated here: _____________________________________________________________________________________________________ Birth Father's Height Patient's Birth Weight ft. lbs. in. oz. Birth Mother's Height Patient's Present Weight ft. lbs. in. Height ft. in.

Custodial Parent(s) or Guardian(s): _____________________________________________________________________________________________________

MOTHERS INFORMATION: Last Name: ______________________________First Name:_______________________________________________________ Address (if different than patient's): _____________________________________________ Phone No. (if different than patient's): ( ) - _____ City: ________________State: ___ Zip/Postal Code:_________

Work: _____________________________ Cell phone/pager: __ ______________________

Email address: ______________________________________________________________________________ Mother's Marital Status: Single: _____Married:______Divorced:______Widowed:______Other:_____________

FATHERS INFORMATION: Last Name: _______________________________First Name:_______________________________________________________ Address (if different than patient's): _____________________________________________________________________________________________________ City: State/Province: ___ Zip/Postal Code: ________________________

Phone number (if different than patient's):__________________________________Work:______________________________ E-mail address: Father's Marital Status: Single:______Married:______Divorced:______Widowed:______Other:_____________ Cell phone/pager:________________________

Name Of Patient's Dentist:

Phone No.: (

)

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Dentist's Address: __________________________________________________________________ City: _________________________ State/Province: Zip/Postal Code:

Date Last Seen: ________________ Reason: ____________________________________________ Name Of Patient's Physician (s): __________________________ Phone No(s).: ( ) -

Physician's Address: __________________________________________________________________ City: ____________________________ Date Last Seen:____________________ State/Province: Zip/Postal Code:

Reason: _________________________________________________________________________________________

Who Is Financially Responsible For This Account? Last Name: Address (if different from patient's): Years at this address: If less than five years, previous address: Phone No. (if different than patient's): ( ) S.S.N/S.I.N .:

First Name: City:

Middle Name/Initial: State: Zip:________

City:

State:

Zip:

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History Form – Adult 06/03

___________________________________ Who suggested that your child might need orthodontic treatment? _________________________________________________________________________________ Why did you select our office? _____________________________________________________________________________________________________________ 2 History Form – Adult 06/03 ./S./S.I. ___________________________________ Secondary Policy Holder's Name: Birth Date: Dental Insurance Company: Medical Insurance Company: S.I.: ____________________________________________________ Employed By: _______________________________________________________________________________________ Group No.: ______________________________ Employed By: ______________________________________________________________________________________ Group No. ___________________________________ Group No.N.N.N.N.S.Employer: Insurance Coverage For Dental Treatment? Yes Primary Policy Holder's Name: Birth Date: Dental Insurance Company: No How many years? Insurance Coverage For Orthodontic Treatment? Yes No S.S.

nutrient supplements. tuberculosis or pneumonia? Problems of the immune system? AIDS or HIV positive? Hepatitis. herbal medications or non prescription medicine? Please name them. Medication Medication Medication Taken for Taken for Taken for MEDICAL HISTORY Now or in the past. no. shortness of breath or swelling ankles? Cardiovascular problem (heart trouble. nose or throat condition? Hayfever. or don't know/understand (dk/u). stroke. any major accidents? Rheumatoid or arthritic conditions? Endocrine or thyroid problems? Kidney problems? Diabetes? Cancer. jaundice or liver problem? Fainting spells. tasting or speech difficulties? Loss of weight recently. anemia or bleeding disorder? High or low blood pressure? Tires easily? Chest pain. approximately when? Is the patient pregnant? FAMILY MEDICAL HISTORY Do the patient’s parents or siblings have any of the following health problems? If so. balloons) Vinyl Acrylic Animals Foods (specify) Other substances (specify) PATIENT PROFILE yes yes yes yes no no no no dk/u dk/u dk/u dk/u Does patient follow directions well? Does patient brush his/her teeth conscientiously? Does patient have learning disabilities or need extra help with instructions? Is patient sensitive or self-conscious about teeth? yes no dk/u Is the patient taking medication. Advil) Penicillin or other antibiotics Sulfa drugs Codeine or other narcotics 3 History Form – Adult 06/03 . A thorough and complete history is vital to a proper orthodontic evaluation. coronary insufficiency. seizures. ear. tumor. hearing. sinus trouble or hives? Tonsil or adenoid conditions? yes no dk/u Does the patient currently have or ever had a substance abuse problem? yes yes yes yes no no no no dk/u dk/u dk/u dk/u Does the patient chew or smoke tobacco? Operations? Describe: Hospitalized? For: Other physical problems or symptoms? Describe: yes no dk/ u Being treated by another health care professional? For: Date of most recent physical exam? Are there any other medical conditions that we should be aware of? GIRLS ONLY yes yes no no dk/u dk/u Has the patient started her monthly periods? If so. epilepsy or neurological problem? Mental health disturbance or behavioral problem? Vision. inborn heart defects. angina. poor appetite? History of eating disorder (anorexia. yes yes yes yes yes yes yes no no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u dk/u Metals (jewelry. The answers are for office records only and will be considered confidential. radiation treatment or chemotherapy? Stomach ulcer or hyperacidity? Polio. Bleeding disorders Diabetes Arthritis Metabolic disturbances Severe allergies Unusual dental problems Jaw size imbalance Any other family medical conditions that we should know about? yes yes yes yes yes yes no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u Allergies or reactions to any of the following: yes yes yes yes yes yes no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u Local anesthetics (Novocaine or Lidocaine) Aspirin Ibuprofen (Motrin.For the following questions mark yes. clothing snaps) Latex (gloves. arteriosclerosis. please explain. mononucleosis. bulimia)? Excessive bleeding or bruising tendency. has the patient had: yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/ u dk/u dk/u Birth defects or hereditary problems? Bone fractures. asthma. heart murmur or rheumatic heart disease)? Skin disorder? Does the patient eat a well-balanced diet? Frequent headaches. colds or sore throats? Eye. heart attack.

jaw clenching clicking or locking? Any pain in jaw or ringing in the ears? Any pain or soreness in the muscles of the face or around the ears? yes yes yes yes yes yes yes yes yes How often does your child brush? Floss? What is your primary concern? Why are you here? I have read and understand the above questions. snoring or difficulty in breathing? Tooth grinding. If there are any changes later to this history record or medical/dental status. teeth throb or ache? Jaw fractures. finger. frequent canker sores or cold sores? Taking any forms of fluoride? Any relative with similar tooth or jaw relationships? Had periodontal (gum) treatment? Would patient object to wearing orthodontic appliances (braces) should they be indicated? yes yes ? yes no no no dk/u dk/u dk/u Any serious trouble associated with any previous dental treatment? Ever had a prior orthodontic examination or treatment? Been under another dentist's care? Specialist Other Now or in the past. broken or missing restorations (fillings)? Any teeth irritating cheek. crooked or protruding teeth? Aware or concerned about under or over developed jaw? "Gum Boils". 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. cysts or mouth infections? "Dead teeth" or root canals treated? Bleeding gums. tongue or palate? Concerned about spaced. Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: _______________________________________________________ Date Signed: ________________ (Dental Staff Member) 4 History Form – Adult 06/03 . lip. bad taste or mouth odor? Periodontal "gum problems"? Food impaction between teeth? Thumb.DENTAL HISTORY yes no no no no no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u Difficulty encountered in chewing or jaw opening? Aware of loose. or sucking habit? Until what age Abnormal swallowing habit (tongue thrusting)? History of speech problems? Mouth breathing habit. I will so inform this practice. has the patient had: yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/u dk/ u dk/u Started teething very early or late? Primary (baby) teeth removed that were not loose? Permanent or "extra" (supernumerary) teeth removed? Supernumerary (extra) or congenitally missing teeth? Chipped or otherwise injured primary (baby) or permanent teeth? Teeth sensitive to hot or cold.

MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES Comments: Signed: ______________________________________________________ Date Signed: ________________ (Parent or Guardian) Signed: ______________________________________________________ Date Signed ________________ (Dental Staff Member) © American Association of Orthodontists 2003 5 History Form – Adult 06/03 .