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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:*
  • First name:*
  • Last name:*
  • I prefer to be called:
  • Date of birth:* (dd/mm/yyyy)
  • Sex:*
  • 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

Financial Responsibility

  • Who is financially responsible for this account?*

Dental Insurance / Medical Insurance

  • Does any dental/orthodontic insurance exist?*

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?*
  • Have you noticed any changes in your face or jaws?*
  • How often do you brush your teeth?*
  • How often do you floss your teeth?
  • Women: Are you pregnant?
  • Women: Are you trying to become pregnant?

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?
Any injuries to face, head, neck?
Arthritis or joint problems?
Diabetes or low sugar?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
High or low blood pressure?
Excessive bleeding or bruising, anaemia?
Heart defects, heart murmur, rheumatic heart disease?
Frequent headaches or migraines?
Asthma, sinus problems, hay fever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

Have you had allergies or reactions to any of the following?

Local anesthetics (novocaine, lidocaine, xylocaine):
Latex (gloves, balloons):
Aspirin or Ibuprofen (Nurofen):
Penicillin:
Metals (jewelry, clothing snaps):
Acrylics:
Other substances:
  • If yes, please state:

Dental History

Now or in the past, have you had:

Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
"Gum boils," frequent canker sores or cold sores?
History of speech problems or speech therapy?
Food impaction between the teeth?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for "TMJ" or "TMD" problems?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

Family Medical History

Have your parents or siblings ever had any of the following health problems?

Bleeding disorders:
Diabetes:
Arthritis:
Severe allergies:
Unusual dental problems:
Jaw size imbalance:
Other family medical conditions:
  • 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.
  • Date:* (dd/mm/yyyy)

* Required fields

Hampstead Orthodontic Practice logo
4 Elm Terrace, Constantine Road.
Hampstead, London. NW3 2LL
enquiries@hampsteadortho.co.uk
020 3733 4187

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