*For the following questions Mark Yes, No, or Don’t Know/Understand (DK/U). The answers are for our office records and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.
PATIENT PROFILE
Medical History
*Now or In the Past, Has The Patient Had:
Please Name Them:
Girls Only
Allergies or reactions to any of the following:
DENTAL HISTORY:
*Now or In the Past, Has The Patient Had: