For the following questions mark Yes, No, or don’t know/understand (Dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.
Personal InformationNameNow or In the past, have you had:Birth defects or hereditary problems?YesNoDk/uBone fractures, any major accidents?YesNoDk/uRheumatoid or arthritic conditions?YesNoDk/uEndocrine or thyroid problems?YesNoDk/uKidney problems?YesNoDk/uDiabetes?YesNoDk/uCancer, tumor, radiation treatment or chemotherapy?YesNoDk/uStomach ulcer or hyperacidity?YesNoDk/uPolio, mononucleosis, tuberculosis, pneumonia?YesNoDk/uProblems of the immune system?YesNoDk/uAIDS or HIV positive?YesNoDk/uHepatitis, jaundice or liver problem?YesNoDk/uFainting spells, seizures, epilepsy or neurological problem?YesNoDk/uMental health disturbance or depression?YesNoDk/uVision, hearing, lasting or speech difficulties?YesNoDk/uLoss of weight recently, poor appetite?YesNoDk/uHistory of eating disorder (anorexia, bulimia)?YesNoDk/uExcessive bleeding or bruising tendency, anemia or bleeding disorder?YesNoDk/uHigh or low blood pressure?YesNoDk/uTired easily?YesNoDk/uChest pain, shortness of breath or swelling ankles?YesNoDk/uCardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, aneriosclerosis, stroke, inborn heart defects,heart murmur or rheumatic heart disease)?YesNoDk/uSkin disorder?YesNoDk/uDo you have a well-balanced diet?YesNoDk/uFrequent headaches, colds or sore throats?YesNoDk/uEye, ear, nose or throat condition?YesNoDk/uHayfever, asthma, sinus trouble or hives?YesNoDk/uTonsil or adenoid conditions?YesNoDk/uOsteoporosis?YesNoDk/uAllergies or reactions to any of the following:Local anesthetics (Novocaine or Lidocaine)YesNoDk/uAspirinYesNoDk/uIbuprofen (Motrin, Advil)YesNoDk/uPenicillin or other antibioticsYesNoDk/uSulfa drugsYesNoDk/uCodeine or other narcoticsYesNoDk/uMetals (jewelry, clothing snaps)YesNoDk/uLatex (gloves, balloons)YesNoDk/uVinylYesNoDk/uAcrylicYesNoDk/uAnimalsYesNoDk/uFoodsYesNoDk/uPlease specify which foods you are allergic to.Other substancesYesNoDk/uPlease specify which other substances you are allergic to.Are you taking medication, nutrient supplements, herbal medications or non prescription medicine?YesNoPlease list which medications or supplements you're taking.Please list the medications you are takingMedicationTaken for Do you currently have or ever had a substance abuse problem?YesNoDk/uDo you chew or smoke tobacco?YesNoDk/uOperations?YesNoDk/uPlease ExplainHospitalized?YesNoDk/uWhat were you hospitalized for?Being treated by another health care professional?YesNoDk/uWhat are you being treated for?Date of most recent physical exam?
Do you have any other medical conditions that we should know about?YesNoPlease explain.Women OnlyAre you pregnant?YesNoDk/uAre you anticipating becoming pregnant?YesNoDk/uFamily Medical HistoryDo your parents or siblings have, or have ever had any of the following health problems? If so, please explain.
Unusual dental problems
Jaw size imbalance
Any other family medical conditions that we should know about?.
Please provide more information about the conditions noted above.Dental HistoryNow or in the past, has the patient had:Permanent or "extra" (supernumerary) teeth removed?YesNoDk/uSupernumerary (extra) or congenitally missing teeth?YesNoDk/uChipped or otherwise injured primary (baby) or permanent teeth?YesNoDk/uTeeth sensitive to hot or cold; teeth throb or ache?YesNoDk/uJaw fractures, cysts or mouth infections?YesNoDk/u"Dead teeth" or root canals treated?YesNoDk/uBleeding gums, bad taste or mouth odor?YesNoDk/uPeriodontal "gum problems"?YesNoDk/uFood impaction between teeth?YesNoDk/u"Gum boils", frequent canker sores or cold sores?YesNoDk/uThumb, finger, or sucking habit?YesNoDk/uUntil what age?Abnormal swallowing habit (tongue thrusting)?YesNoDk/uHistory of speech problems?YesNoDk/uMouth breathing habit, snoring or dfficulty in breathing?YesNoDk/uTooth grinding or jaw clenching?YesNoDk/uAny pain, clicking or locking inj aw or ringing in the ears?YesNoDk/uAny pain or soreness in the muscles of the face or around the ears?YesNoDk/uDifficulty in chewing or jaw opening?YesNoDk/uHave you ever been treated tor "TMD"or "TMJ" problems?YesNoDk/uAware loose, broken or missing restorations (fillings)?YesNoDk/uAny teeth irritating cheek, lip, tongue or palate?YesNoDk/uConcerned about spaced, crooked or protruding teeth?YesNoDk/uAware or concerned about under or over developed jaw?YesNoDk/uAny relative with similar tooth or jaw relationships?YesNoDk/uAny wisdom tooth problems?YesNoDk/uHad periodontal (gum) treatment?YesNoDk/uHad any serious trouble associated with any previous dental treatment?YesNoDk/uBeen under another dentist's care?YesNoDk/uBeen under another specialist's care?YesNoDk/uBeen under any other's care?YesNoDk/uEver had a prior orthodontic examination or treatment?YesNoDk/uWould you object to wearing orthodontic appliances (braces) should they be indicated?YesNoDk/uHow often do you brush?How often do you floss?What is your primary concern?Terms & Conditions
I have read and understand the above questions. 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. If there are any changes later to this history record or medical/dental status, I will so inform this practice.
170 Benney Ln #103
Dripping Springs, TX 78620
(512) 894-3779 |
Pediatric Dental Services
1910 W. 35th Street
Austin, TX 78703
(512) 451-8310 |