Medical Dental History Form for Patients Under Age 18

Patient

Parent/Guardian

Dentist

General Information

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).

Medical History

Now or in the past, has your child had:

Yes No DK/U

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

Yes No DK/U

Dental History

Now or in the past, has your child had:

Yes No DK/U

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.

Release and Waiver

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my child’s medical or dental health.