Orthodontic Patient Medical History Form
Patient Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Address
Responsible Party (If patient is a minor)
Name
Relationship
Phone Number
Physician Information
Physician Name
Physician Phone
Medical History
Are you currently under a physician's care?
Yes
No
If yes, please explain
List any medications you are currently taking
Allergies (including drugs/latex/others)
Have you ever had or do you have any of the following?
Heart Disease
High Blood Pressure
Diabetes
Epilepsy
Asthma
Hepatitis
Bleeding Disorders
Tuberculosis
Other
If other, please specify
Dental History
Reason for orthodontic evaluation/treatment
Have you had previous orthodontic treatment?
Yes
No
Do you have any of the following oral habits?
Thumb Sucking
Mouth Breathing
Teeth Grinding
Nail Biting
Other
If other, please specify
Date of last dental check-up
Dentist name
Additional comments