Private Medical Dental History Form (Adult) A thorough medial history is essential to a complete orthodontic evaluation. This form will take less than 10 minutes to complete. Your answers are for office records only, and are confidential. Patient Title:* MrMrsMsMissDrOther First name:* Last name:* I prefer to be called: Date of birth:* (dd/mm/yyyy) Sex:* MaleFemale Home address:* Postcode:* Email:* Home phone:* Mobile phone: Work phone: Dentist Dentist name:* Dentist address:* General Information What concerns you about your teeth? Who suggested that you might need orthodontic treatment?* Why did you select our office?* Have you had any previous orthodontic treatment? Please describe: Have any other family members been treated in this office? Please name them: Can you think of any friend/family member you would like us to contact regarding possible treatment? The British Orthodontic Society recommends a child be assessed from the age of 7 and onwards. Do you have any children you would like to register with us? click here Name: (1st child) Date of birth: (dd/mm/yyyy) Name: (2nd child) Date of birth: (dd/mm/yyyy) Name: (3rd child) Date of birth: (dd/mm/yyyy) Financial Responsibility Who is financially responsible for this account?* Dental Insurance / Medical Insurance Does any dental/orthodontic insurance exist?* YesNo Patient Health Information List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take: Taken for: Do you chew or smoke tobacco?* YesNo Have you noticed any changes in your face or jaws?* YesNo How often do you brush your teeth?* How often do you floss your teeth? Women: Are you pregnant? YesNoN/A Women: Are you trying to become pregnant? YesNoN/A Medical History For the following questions set yes, no, or don't know. Now or in the past, have you had: Birth defects or hereditary problems? YesNoDont Know Any injuries to face, head, neck? YesNoDont Know Arthritis or joint problems? YesNoDont Know Diabetes or low sugar? YesNoDont Know AIDS or HIV positive? YesNoDont Know Hepatitis, jaundice or other liver problem? YesNoDont Know Seizures, fainting spells, neurologic problem? YesNoDont Know Mental health disturbance or depression? YesNoDont Know Vision, hearing, or speech problems? YesNoDont Know High or low blood pressure? YesNoDont Know Excessive bleeding or bruising, anaemia? YesNoDont Know Heart defects, heart murmur, rheumatic heart disease? YesNoDont Know Frequent headaches or migraines? YesNoDont Know Asthma, sinus problems, hay fever? YesNoDont Know Tonsil or adenoid condition? YesNoDont Know Do you frequently breathe through your mouth? YesNoDont Know Have you had allergies or reactions to any of the following? Local anesthetics (novocaine, lidocaine, xylocaine): YesNoDont Know Latex (gloves, balloons): YesNoDont Know Aspirin or Ibuprofen (Nurofen): YesNoDont Know Penicillin: YesNoDont Know Metals (jewelry, clothing snaps): YesNoDont Know Acrylics: YesNoDont Know Other substances: YesNoDont Know If yes, please state: Dental History Now or in the past, have you had: Permanent or extra (supernumerary) teeth removed? YesNoDont Know Supernumerary (extra) or congenitally missing teeth? YesNoDont Know Chipped or injured primary or permanent teeth? YesNoDont Know Any sensitive or sore teeth? YesNoDont Know Bleeding gums, bad taste or mouth odor? YesNoDont Know Jaw fractures, cysts, infections? YesNoDont Know Any teeth treated with root canals or pulpotomies? YesNoDont Know "Gum boils," frequent canker sores or cold sores? YesNoDont Know History of speech problems or speech therapy? YesNoDont Know Food impaction between the teeth? YesNoDont Know Frequent oral habits (sucking finger, chewing pen, etc.)? YesNoDont Know Teeth causing irritation to lip, cheek or gums? YesNoDont Know Abnormal swallowing (tongue thrust)? YesNoDont Know Tooth grinding or clenching? YesNoDont Know Clicking, locking in jaw joints? YesNoDont Know Soreness in jaw muscles or face muscles? YesNoDont Know Ringing in ears, difficulty in chewing or opening jaw? YesNoDont Know Have you ever been treated for "TMJ" or "TMD" problems? YesNoDont Know Any serious trouble associated with previous dental treatment? YesNoDont Know Have you ever been diagnosed with gum disease or pyorrhea? YesNoDont Know Have you ever had an orthodontic consultation or treatment before now? YesNoDont Know Family Medical History Have your parents or siblings ever had any of the following health problems? Bleeding disorders: YesNoDont Know Diabetes: YesNoDont Know Arthritis: YesNoDont Know Severe allergies: YesNoDont Know Unusual dental problems: YesNoDont Know Jaw size imbalance: YesNoDont Know Other family medical conditions: YesNoDont Know If so, please explain: Waiver I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health. I accept these terms* Date:* (dd/mm/yyyy) * Required fields Please leave this field empty.