Orthodontic Patient History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Phone Number
Address
Email
Dental/Medical History
Name of Physician
List any medical conditions
List any medications currently being taken
Have you had any surgeries?
Yes
No
Reason for orthodontic consultation
Allergies (including latex, medications, etc.)
Family Dental History
Is there a family history of orthodontic treatment?
Yes
No
If yes, please specify
Additional Information
Other relevant information