Michalkow Adult

Dentist:

City:

Phone:

Date of last dental check-up?

How many times do you brush your teeth daily?

What is your main orthodontic concern?

Have you ever been evaluated for orthodontic treatment before?

Yes No

If yes, when?

Have you been informed of any missing or extra permanent teeth?

Yes No

if yes, which teeth?

Have you ever had pain/tenderness in your jaw joint (TMJ/TMD)?

Yes No

when?

Personal Physician:

City:

Phone:

Please list all medications you are currently taking:

MEDICAL - DENTAL HISTORY

COVID-19:

Yes No

Convulsions/Epilepsy:

Yes No

Congenital Heart defect:

Yes No

ADD/ADHD:

Yes No

Kidney/Liver problems:

Yes No

Tongue Thrusting:

Yes No

Asthma:

Yes No

Vision Impairment:

Yes No

Lupus:

Yes No

Allergy to Drugs:

Yes No

Handicaps/Disabilities:

Yes No

Thumb/Finger Sucking:

Yes No

Allergies to Latex:

Yes No

Hearing Impairment:

Yes No

Clenching/Grinding:

Yes No

Heart Murmur:

Yes No

Speech Problems:

Yes No

Diabetes:

Yes No

Snoring:

Yes No

Hemophilia:

Yes No

Allergies to Nickel/Metal:

Yes No

HIV+/AIDS:

Yes No

Tuberculosis (TB):

Yes No

Cancer:

Yes No

Tonsillectomy

Yes No

Adenoidectomy

Yes No

Mouth Breathing

Yes No

Other medical findings/List of Drug Allergies:

Whom may we thank for referring you to our office?

Patient signature

Date:

RESPONSIBLE PARTY INFORMATION

ORTHODONTIC INSURANCE INFORMATION

Insurance information cannot be veriﬁed unless the Group ID# is provided. If the group ID# shown on your insurance card diﬀers from your social security number, we will also need your social security number.

CONTINUED...

MEDICAL - DENTAL HISTORY