Health-History-Form | Ogradysmiles

Patient Information for O'Grady Orthodontics

Patient's Name:

Birthday:

Dentist:

Last dental checkup:

Physician:

If the patient is a child, please list names and ages of other siblings

Whom may we thank for referring you to our office?

If patient is an adult, please fill out information below

Home Phone:

Cell Phone:

Email:

Work Phone:

O.K. to contact at work? Yes No (circle one)

Employer:

Social Security#

Occupation:

No. years employed:

Marital Status:

Single

Married

Divorced

Widowed (circle one)

If married spouse's name

If patient is a minor, please fill out information below

Father's Name:

Birthday:

Home Phone:

Cell Phone:

Email:

Work Phone:

O.K. to contact at work? Yes No (circle one)

Employer:

Social Security#

Occupation:

No. years employed:

Marital Status:

Single

Married

Divorced

Widowed (circle one)

If married spouse's name

Mother's Name:

Birthday:

Home Phone:

Cell Phone:

Email:

Work Phone:

O.K. to contact at work? Yes No (circle one)

Employer:

Social Security#

Occupation:

No. years employed:

Marital Status:

Single

Married

Divorced

Widowed (circle one)

If married spouse's name

If the address of the parents is different, which parent does the child reside with? (circle one)

Mother Father

Patient's Signature or Parent's if minor

Date

Patient's Name:

Date:

If you are completing this form for another person, what is your relationship to that person?

1. Are you in good health?

Yes No

2. Has there been any change in your general health within the past year?

Yes No

3. Are you now under the care of a physician)?

Yes No

If so, what is the condition being treated?

4. Do you have or have had any of the following diseases or problems?

a. Damaged heart valves or artificial heart valves, including heart murmur

Yes No

If yes, is premedication necessary?

Yes No

b. Congenital heart lesions

Yes No

c. Cardiovascular disease (heart trouble, heart attack, coronary insufficiency,

coronary occlusion, high blood pressure, arteriosclerosis, stroke)

Yes No

d. Allergies or hay fever

Yes No

e. Sinus trouble

Yes No

f. Asthma

Yes No

g. Fainting spells or seizures

Yes No

h. Diabetes

Yes No

i. Hepatitis, jaundice or liver disease

Yes No

j. Arthritis

Yes No

k. Inflammatory rheumatism (painful swollen joints)

Yes No

l. Low blood pressure

Yes No

m. Epilepsy

Yes No

n. Cancer

Yes No

o. ADIS or other immunosuppressive disorders

Yes No

p. TMJ symptoms

Yes No

Other

5. Have the tonsils and adenoids been removed?.

Yes No

6. Do you suffer from frequent sore throats?

Yes No

7. Oral habits (thumb, finger, pacifier)? If so, how long?

Yes No

8. Do you mouth breath?

Yes No

9. Do you snore while sleeping?

Yes No

10. Have you had abnormal bleeding associated with previous extractions, surgery or trauma)

Yes No

11. Have you had any previous periodontal (gum) treatment?

Yes No

12. Have you had surgery, x-ray or drug treatment for a tumor, growth, or other condition of your head or neck?

Yes No

13. Are you taking any drug or medicine? If so, what?

Yes No

14. Do you smoke or chew tobacco? If so, which one and how often?

Yes No

15. Are you allergic or have you reacted adversely to:

a. Local anesthetics

Yes No

b. Penicillin or other antibiotic

Yes No

c. Sulfa drugs

Yes No

d. Barbiturates, sedatives, or sleeping pills

Yes No

e. Aspirin

Yes No

f. Lodine

Yes No

g. Codeine or other narcotics

Yes No

Other

16. Have you had any serious trouble associated with any previous dental treatment?

Yes No

17. Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes No

18. Are you pregnant?.

Yes No

19. Has menstruation started? If so, when?

Yes No

20. Has there been a voice change? If so, when?

Yes No

Chief concern about the teeth

I certify that I have read and understand the above. I acknowledge that any questions I have about the inquires set forth above have been answered to my satisfaction.

Signature of patient/parent or guardian

Date

Patient Information for O'Grady Orthodontics

If patient is an adult, please fill out information below

If patient is a minor, please fill out information below

Medical History for O'Grady Orthodontics

In the following questions, circle yes or no, whichever applies. Your answers are for our records only and will be considered confidential

Women

Girls

Boys