Name
west orthodontics
JEREMY T. WEST D.D.S.
Date
Medical and Dental History
MEDICAL HISTORY
1. Has the patient been under care of a physician in the last two years?
YES
NO
2. Is the patient taking any medications?
YES
NO
3. Is the patient subject to prolonged bleeding after injury or cut?
YES
NO
4. Does the patient have emotional problems?
YES
NO
5. Has the patient had a history of:
Rheumatic fever?
YES
NO
Diabetes?
YES
NO
Allergies?
YES
NO
Heart trouble?
YES
NO
Asthma?
YES
NO
Kidney or liver involvement?
YES
NO
Thyroid imbalance?
YES
NO
Rheumatoid arthritis?
YES
NO
Other Disorders?
YES
NO
6. Is the patient subject to:
Nervous disorders?
YES
NO
Fainting?
YES
NO
Dizzieness?
YES
NO
Epilepsy?
YES
NO
Persistent headaches?
YES
NO
7. Has the patient had tonsils or adenoids removed?
YES
NO
8. Has the patient ever been hospitalized or had any operations not mentioned above?
YES
NO
9. Does the patient have any allergic reactions to:
Local Anesthetics? (Novocaine or Lidocaine)
YES
NO
Asprin?
YES
NO
Ibuprophen? (Motrin, Advil)
YES
NO
Penicillin or other antibiotics?
YES
NO
Sulfa drugs?
YES
NO
Codeine or other narcotics?
YES
NO
Metals? (jewelry, clothing snaps)
YES
NO
Latex?
YES
NO
Vinyl or Acrylic?
YES
NO
Foods?
YES
NO
Other?
YES
NO
10. Has the patient ever taken any type of oral or intravenous bisphosphonates?
YES
NO
11. Is the patient pregnant?
YES
NO
MEDICAL HX CONTINUED
12. Does the patient chew or smoke tobacco?
YES
NO
13. Has the patient had any operations?
YES
NO
14. Has the patient been hospitalized?
YES
NO
15. Are there any other medical conditions that we should be aware of?
YES
NO
DENTAL HISTORY
1. Patient’s last dental cleaning?
2. Has the patient ever sucked a thumb or finger?
YES
NO
Other
At what age?
3. Does the patient breathe excessively through his /her mouth?
YES
NO
4. Have you noticed any speech disorders?
YES
NO
5. Does the patient have pain or clicking in the jaw joint when chewing or opening wide?
YES
NO
6. Has the patient ever been treated for jaw joint pain?
YES
NO
7. Any injury to teeth or jaw in an accident or fall?
YES
NO
Extra teeth?
YES
NO
8. Were any teeth (baby or permanent) removed by extraction?
YES
NO
9. Have the teeth been subject to any falseuoride treatment?
YES
NO
10. Has the patient had any previous orthodontic care?
YES
NO
11. Has the patient had any periodontal issues? (gum problems)
YES
NO
12. Has the patient experienced any of the following:
Abnormal swallowing?
YES
NO
Excessive tooth grinding?
YES
NO
Speech problems?
YES
NO
Tooth trauma?
YES
NO
Airway obstruction?
YES
NO
13. Are there any other dental issues that we should be aware of?
YES
NO
INITIAL HEALTH HISTORY
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INITIAL HEALTH HISTORY
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If you answered “yes”, please explain here: