PSJ ORTHODONTICS PATIENT MEDICAL HISTORY FORM

Date

PATIENT INFORMATION

First Name:

Middle Initial:

Last Name:

Nickname:

Birthdate:

Gender:

E-mail:

Street Address 1:

Street Address 2:

City:

State:

Zip:

Main phone:

Cell phone:

Family/Friends in PSJ:

Referred by:

Sports/Hobbies:

School:

Grade:

RESPONSIBLE PARTY INFORMATION

Check if the patient is also the person who will be financially responsible for treatment.

First Name:

Middle Initial:

Last Name:

Birthday:

Relationship to patient:

Email:

Responsible party address is the same as the patient

Street Address 1:

Street Address 2:

City:

State:

Zip:

Cell:

Occupation:

Employer:

SSN#:

Second Parent or Guardian

First Name:

Middle Initial:

Last Name:

Relationship to patient:

Email:

Address (if different from patient):

City:

State:

Zip:

Cell:

Occupation:

Employer:

SSN#:

DENTAL INSURANCE INFORMATION

Insurance company 1:

Subscriber Name:

Date Of Birth:

Employer:

Subscriber#-SSN:

Group #:

Phone#:

Insurance company 2:

Subscriber Name:

Date Of Birth:

Employer:

Subscriber#-SSN:

Group #:

Phone#:

DENTAL HISTORY

Name of Dentist:

Last Dental Visit:

Address:

City:

State:

Zip:

Dentist Phone Number:

Dentist Email:

Has the patient previously had an orthodontic consultation or treatment?

Yes

If ‘Yes’, When?

Does the patient pre-medicate prior to dental visits?

Yes

Main Orthodontic Concern:

Please indicate whether or not the patient has had any of the conditions listed below either now or in the past.

Speech problem/therapy

Yes

Injury to face, jaw, teeth or mouth

Yes

Frequent headaches

Yes

Teeth sensitivity to hot or cold

Yes

Mouth breathing

Yes

Apprehension about dental care

Yes

Bleeding gums

Yes

Clench or grind teeth

Yes

Chipped or injured permanent teeth

Yes

Previous periodontal (gum) treatment

Yes

Snores during sleep

Yes

Jaw fractures, cysts, mouth infections

Yes

Frequent canker sores or cold sores?

Yes

Thumb or finger habit

Yes

If yes, age when stopped:

Explanations and other dental concerns:

TMJ HISTORY

Have you ever been treated for TMJ?

Yes

Do you experience soreness in the muscles of your face or around your ears?

Yes

Do you have pain, tenderness or noise in your jaw?

Yes

Do you have a history or jaw joint problems?

Yes

Do you notice clicking or popping in your jaw joint?

Yes

Explanations and other TMJ concerns:

MEDICAL HISTORY

Physician's Name

Address

Date of last physical?

List any drug medications patient is currently taking (including non-prescription)

Have there been any changes in health in the past 5 years?

Yes

Is the patient under a physician’s care (other than routine)?

Yes

If yes, for what?

Has patient had serious injury/hospitalization in the last 5 years?

Yes

ALLERGIES OR DRUG REACTIONS

PENICILLIN/ ANTI-BIOTICS

Yes

SULFA DRUGS

Yes

CODEINE/ NARCOTICS

Yes

ASPIRIN/ IBUPROFEN/ ACETOMENOPHIN

Yes

LATEX

Yes

METAL

Yes

PEANUTS

Yes

List any other allergies or sensitivities the patient may have:

Please indicate whether or not the patient has had any of the conditions listed below either now or in the past.

Heart murmur

Yes

Damaged or artificial heart valves

Yes

Congenital heart defect

Yes

Heart attack/ Stroke

Yes

Hypertension/ High Blood Pressure

Yes

Liver disease/ Jaundice/ Hepatitis

Yes

Diabetes

Yes

Prolonged bleeding/ Transfusion

Yes

HIV/ AIDS

Yes

Anemia/ blood disorder

Yes

Asthma

Yes

Tonsils Removed

Yes

Adenoids Removed

Yes

Sinus trouble

Yes

Arthritis/ Joint problems

Yes

Bone disorders/ loss

Yes

Seizures/ Epilepsy/ Neurological disease

Yes

Emotional problems

Yes

Growth problems

Yes

Is the patient pregnant?

Yes

Does the patient take bisphosphonates (Fosamax or Boniva)

Yes

Is there anything else we need to know about the patient’s medical history? Explain any questions answered with a ‘yes’.

Under 18

Height:

Weight:

Has patient begun puberty?

Yes

Has patient grown in the last year?

Yes

Has the patient’s shoe size changed in the last year?

Yes

Girls: Has menstruation begun?

Yes

Boys: Has voice changed or facial hair come in?

Yes

Has either biological parent had orthodontic treatment?

Yes

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform PSJ Orthodontics.

Signature

Date:

Relationship to patient: