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Private Medical Dental History Form (Under 18)

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:*
  • Ethnicity:
  • Hobbies/activities:
  • School:
  • Grade:
  • Home address:*
  • Postcode:*
  • Email:*
  • Home phone:*
  • Mobile phone:

Parent/Guardian

  • Patient lives with (check all that apply):
    *
  • Parent's title:*
  • Parent's full name:*
  • Home address: (if different)
  • Home phone: (if different)
  • Mobile phone:
  • Work phone:

Dentist

  • Dentist name:*
  • Dentist address:*

General Information

  • How often does your child brush?*
  • How often does your child floss?
  • What concerns you about your child's teeth?
  • Do you think that any of your child's activities affect his/her face, teeth or jaws?
    If so, how:
  • Have you noticed any unusual changes in your child's face or jaws?
  • How does your child feel about orthodontic treatment?
  • Who suggested that your child might need orthodontic treatment?*
  • Why did you select our office?*
  • Describe any previous orthodontic treatment or consultations:
  • Have any other family members been treated in this office?
    Please name them:
  • Are you considering private orthodontic treatment?*
  • Can you think of any friend 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 siblings you would like to register with us? click here

Financial Responsibility

  • Who is financially responsible for this account?*

Medical History

For the following questions set yes, no, or don't know.

Now or in the past, has your child had:

Any injuries to face, head, neck?
Endocrine or thyroid problems?
Diabetes or low sugar?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problems?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising tendency, anaemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Skin disorder (other than common acne)?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hay fever?
Tonsil or adenoid condition?
Does your child frequently breathe through his/her mouth?

Has your child had allergies or reactions to any of the following?

Local anesthetics:
Latex (gloves, balloons):
Ibuprofen, Aspirin:
Penicillin:
Other substances:
Metals (jewelry, clothing snaps):
Acrylics:
Plant pollens:
Animals:
Foods:

Dental History

Now or in the past, has your child had:

Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
Frequent ulcers or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for "TMJ" or "TMD" problems?
Any serious trouble associated with previous dental treatment?
Has your child ever been diagnosed with gum disease or pyorrhea?

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

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

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