Smile-Eliason

CONFIDENTIAL Medical – Dental History Form

Patient Information:

Date

Last Name

First Name

Middle Initial

Date of Birth

Male Female

Medical History:

Physician’s name

Physician’s phone

Date last seen

Patient is in good health? Yes No

If no, why?

Do you think that any of your / your child’s activities affect your / his / her teeth or jaws? How?

Yes No

For the following questions, please mark yes or no:

Yes No

Birth defects or hereditary problems?

Yes No

Bone fractures or major injuries?

Yes No

Any injuries to face, head or neck?

Yes No

Arthritis or joint problems?

Yes No

Cancer, tumor, radiation treatment or chemotherapy?

Yes No

Endocrine or thyroid problems?

Yes No

Diabetes or low sugar?

Yes No

Kidney problems?

Yes No

History of osteoporosis?

Yes No

Gonorrhea, syphilis, herpes, sexually transmitted diseases?

Yes No

AIDS or HIV positive?

Yes No

Hepatitis, jaundice, or other liver problems?

Yes No

Polio, mononucleosis, tuberculosis, pneumonia?

Yes No

Seizures, fainting spells, neurologic problems?

Yes No

Mental health disturbance or depression?

Yes No

History of eating disorder (anorexia, bulimia)?

Yes No

Frequent headaches or migraines?

Yes No

High or low blood pressure?

Yes No

Excessive bleeding or bruising, anemia?

Yes No

Chest pain, shortness of breath, tire easily, swollen ankles?

Yes No

Heart defects, heart murmur, rheumatic heart disease?

Yes No

Angina, arteriosclerosis, stroke or heart attack?

Yes No

Skin disorder (other than common acne)?

Yes No

Do you / or does your child eat a well balanced diet?

Yes No

Vision, hearing or speech problems?

Yes No

Frequent ear infections, colds, throat infections?

Yes No

Asthma, sinus problems, hayfever?

Yes No

Tonsil or adenoid condition?

Yes No

Frequently breathe from mouth?

Yes No

Have you / or has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid),
Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer

Yes No

Have you / or has your child ever taken oral bisphonates such as Fosamax (alendronate), Actone (ridendronate),
Boniva (ibandrobate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?

Yes No

Any other physical problems? Explain:

Have you / or has your child had allergies or reactions to any of the following?

Yes No

Please mark yes or no:

Yes No

Local anesthetics (novacaine, lidocaine, xylocaine)

Yes No

Latex (gloves, balloons)

Yes No

Aspirin

Yes No

Ibuprofen (Motrin, Advil)

Yes No

Penicillin

Yes No

Foods List:

Yes No

Other antibiotics List:

Yes No

Metals (jewelry, clothing snaps)

Yes No

Acrylics

Yes No

Plant pollens

Yes No

Animals

Yes No

Other substance List:

Medications: Please list any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take / or your child takes.

Medication

Taken for

Medication

Taken for

Medication

Taken for

Medication

Taken for

Dental History:

Dentist’s name

Dentist’s phone

Date last seen

Other dentists/dental specialists now being seen: Name

City

Reason

Have you / or has your child had any injuries to the mouth/jaw area? Yes No

Explain:

Is this your first orthodontic visit? Yes No

Has your dentist mentioned an orthodontic problem? Yes No

Explain:

Any pain or clicking when opening mouth? Yes No

Release and Waiver:

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

Patient/Guardian Signature

Date

I have read the above questions and understand them. I will not hold my orthodontist or his/her staff responsible for any errors or omissions that I have made in completion of this form. I will notify my orthodontist of changes in my / my child’s medical or dental health.

Patient/Guardian Signature

Date