Stoll Orthodontics | Thornton CO

Medical History

    Medical History
    Patient's Name

    Is patient in good health?

    YesNo

    Does patient have any history of illness?

    YesNo

    Please choose any of the following that the patient was treated for:

    DiabetesTuberculosisEndocrineProblemsProlongedBleedingPneumoniaAnemiaHeartTroubleEpilepsyDizzinessNervousDisordersBoneDisordersKidneyDisordersRheumaticFeverAsthmaNasalBlockageLiverDisorders

    Does patient have tendency toward:

    ColdsSore ThroatsEar InfectionsHeadaches

    Has patient ever been exposed to:

    HerpesAIDSHepatitis

    Have tonsils and/or adenoids been removed?

    YesNo

    Dental History
    Does patient want teeth straightened?

    YesNo

    Does patient have speech problems?

    YesNo

    Has patient ever sucked a thumb or a finger?

    YesNo

    Does patient breathe through the mouth while awake?

    YesNo

    or while asleep?

    YesNo

    Has patient been informed of any missing teeth?

    YesNo

    any extra teeth?

    YesNo

    Does patient have popping jaw or pain in jaw?

    YesNo

    frequent headaches?

    YesNo

    Has patient had injuries to the face or jaw?

    YesNo

    clinch or grind teeth?

    YesNo

    Family History
    Please list the children in your family and indicate if they had had orthodontic treatment.
    Orthodontics

    YesNo

    Orthodontics

    YesNo

    Orthodontics

    YesNo

    Orthodontics

    YesNo

    Has either parent had orthodontic treatment?

    YesNo

    Are you aware that some appointments will infringe on school time?

    YesNo

    Have you previously consulted an orthodontist?

    YesNo